In a famous episode in the TV series Mad Men, Don Draper paid for an advertisement in the New York Times titled,  “Why I’m Quitting Tobacco.” While Draper continued to smoke (the advertisement was a retaliation against Lucky Strike cigarettes over a lost contract), the scene pays tribute to the real crusade of Emerson Foote, an ad man who resigned from McCann-Erickson rather than continue working for tobacco clients.

With another round of stories and studies about Chronic Traumatic Encephalopathy (CTE) published just in time for the start of football season, some NFL players have recently followed Foote’s path by walking away from the game out of concerns for their long-term health. My favorite NFL player has been lumped into this group, possibly erroneously.

I admire John Urschel because I personally endured dumb football player (or worse, dumb lineman) stereotypes in high school from my teachers. Urshel has pressed back against this stereotype with his well known reputation as the Baltimore Ravens lineman who published “A Cascadic Multigrid Algorithm for Computing the Fiedler Vector of Graph Laplacians” in The Journal of Computational Mathmatics during his spare time. I have never met the man, but to fellow Penn State alums, Urshel’s exploits on the field and in the classroom rank among the best stories out of Happy Valley in recent years.

The recent retirement of Urshel, a doctoral candidate in mathematics at the Massachusetts Institute of Technology (MIT), revived the conversation about the safety of football. As a high school teacher and coach, I reflect on the questions of player safety often and wonder if I am sponsoring a sport jeopardizing my players’ future.

After deep thought and careful reading, I always reach the same conclusion: Playing high school football is a good risk to take if a young man wants to play the game.

To some, this sounds as irrational as denying climate change (no, really, that would be crazy), yet I’ve known even bright, well-read individuals and educators who manage to reach incredibly ignorant conclusions on the health risks of football. I had a bright, well-read friend state in the faculty room matter-of-factly, “The average NFL player dies around age 45.” In reality, the CDC reports NFL players outlive the average American male, with the actual life expectancy of an NFL player around 77.6 years.

In 2007, Rep. Linda Sánchez of California compared the NFL to big tobacco companies. There are many, many vices in college and professional football, but questioning preliminary CTE research is not on the same level as covering up millions of cancer patients. These morbid comparisons oversimplify research of CTE, and can provide a dangerously misleading picture.

I’ve sought out informed sources to combat my occupational bias. I read of the studies by the McKee group in Boston, and I am familiar with the work of Bennett Omalu. While others may take the media reports at face value, I looked beneath the surface, I found lingering questions about these findings.

After reading an article by AJ Perez about the most recent McKee group study, some statistics nagged at me. I decided I needed to read the actual report rather than relying on headlines. After struggling with the Journal of the American Medical Association’s registration process and paying $30 for 24 hour single article access, I found some fascinating nuggets in the full journal article.

Background Information

The article discussed in the news frequently in the past week, officially titled “Clinicopathological Evaluation of Chronic Traumatic Encephalopathy in Players of American Football” was published in the Journal of the American Medical Association on July 25th. The study was led by Dr. Jesse Mez, Dr. Daniel H. Daneshvar, and Patrick T. Kiernan, but was backed by Dr. Ann McKee’s CTE Center at Boston University.

Most critics of the article focus on the fact that this study, as well as most of the studies related to CTE, has a selection bias. The researchers openly admit this, as their brain banks only exist from donations. Those who believe they have symptoms of CTE are more likely to donate their brains to the study posthumously. In addition, there is no control group. The study only looked at football players, and did not look at how they compared with other brain donors. Finally, there is no way to measure CTE today without a post-mortem autopsy. Many other approaches are being tested, but the only reliable research right now involves studying the deceased.

Some have said this article is more of the same, but if you dig deeper, you find the most recent article paints a more complicated picture of CTE.

Following disagreements among the international community of scientists over the definition of CTE, the National Institute of Health held a summit in 2015 which led to the categorizing CTE into four stages. The first two stages are considered mild CTE, and can be asymptomatic. While this means an individual can have CTE without behavioral symptoms, all of the brains studied in this report had behavioral symptoms. (Again, if the donor did not have cognitive or behavioral/mood symptoms, they likely would not have considered donating their brain.)

This is the first time I have seen the data broken out between mild and severe CTE, which leads to several interesting findings. Keep in mind that I am not arguing CTE is not dangerous. I simply feel the data does not support sudden and widespread fear. Our understanding of concussions and CTE still seems very raw.

CTE and Suicide 

The modern discussion of CTE began with the story of Mike Webster, a former Pittsburgh Steeler who struggled with mental illness and committed suicide. Bennet Omalu’s autopsy of Webster documented a buildup of tau protein that would become the marker of CTE. The national discussion of CTE has continued on largely because of other high profile suicides of former NFL players.

Of the 177 brains donated for the study, 44 had mild CTE (Stage 1 or Stage 2), and 133 had severe CTE (Stage 3 or 4).

Of the 44 donors with mild CTE, the most common cause of death is suicide. If you isolate that sentence, it sounds like a good headline for a news story, but dig deeper.

Only 18 of the 177 donors died of suicide, and 12 of the 18 donors who committed suicide (67%) only had mild CTE, not severe CTE.

I find this very troubling. If most of the players who committed suicide only had mild CTE, were these tragedies a manifestation of CTE, or did the constant coverage of CTE lead these men to feel their condition would only worsen until they too were supergluing their teeth in?

Family members say former NHL player Todd Ewen shot himself, largely because he believed that he had CTE and his quality of life would steadily decline. His autopsy found he did not have CTE. (His brain was not included in this study, because only football players were studied.)

One of the donors studied was likely Kosta Karageorge, a former athlete at Ohio State. In November 2014, Karageorge’s sudden disappearance drew national attention. His body was found the following week, and one of his final text messages stated “my heads been so [expletive] latly from a these concussioms i really am sorry.”

The media immediately returned to stories the dangers of football and the connection with CTE. There are two distinct problems with the narrative that followed Karageorge’s suicide.

First, Karageorge only played one season at Ohio State after exhausting his wrestling eligibility. Critics of football used Karageorge as a case study, but we do not know how many concussions contributing to CTE were from football as opposed to his wrestling career. The popularity of football draws attention from researchers and reporters, but concussion and CTE risks in other sports are discussed with far less frequency.

Most importantly, despite Karageorge’s documented depression and headaches, the Franklin County coroner’s office originally ruled Karageorge did not have CTE. The brain was later reviewed by McKee’s group in Boston which ruled Karageoge had the Stage 1, or mild CTE, but McKee could not conclude that CTE was the cause of Karageorge’s suicide.

Every suicide is a tragedy, but it is horrifying to consider that some of these deaths may have resulted from misconceptions about CTE.

Intervening Variables

The study by Mez, et. al. also analyzed standard informant reports submitted by 111 of the 177 donors. Of these donors, 47 reported cognitive symptoms, 48 reported behavior/mood symptoms, and 16 reported both cognitive and behavior/mood symptoms. Then, they slipped in this observation about the 48 donors isolated with behavior/mood symptoms:

“Substance use disorders, suicidality, and family history of psychiatric illness were common among those who initially presented with behavior or mood symptoms, occurring in 32 (67%), 22 (47%), and 23 (49%) cases, respectively.”

To what degree does CTE influence behavior/mood symptoms of this sample if 2/3 of the donors reported substance abuse issues and half have a family history of mental health issues?

Another chart indicates that 59 of all 111 donors who filled out the standardized informant report (53%) reported substance abuse, 44 (41%) abused alcohol, 4 (4%) abused anabolic steroids, and 37 (34%) cited “Other” substance abuse.

With such a high rate of intervening variables, you cannot calculate how much football led to impulsivity, depression, anxiety, and all the other documented behavior/mood symptoms, assuming football caused their CTE. Some may argue football led to these other problems. However, I know too many healthy, well functioning former football players for me to believe the rates of substance abuse and mental health issues in this sample match those of the general population of former football players.

How Severe is Severe CTE?

Of the 133 brains that showed severe CTE, the leading cause of death was neurodegenerative diseases (Parkinson’s, Alzheimer’s, Dementia).

Sounds like another easy headline, right? Hold on.

Of these 133 brains with severe CTE, 62 donors (47%) died of neurodegenerative diseases. Of all 177 donated brains, 69 donors (39%) died of neurodegenerative diseases.

Let’s put those numbers in context. Of the convenient sample of those who donated their brains to the study, likely in the belief that they had CTE based on their symptoms, less than 4 out of 10 died of neurodegenerative disease (Parkinson’s, Alzheimer’s, Dementia), including less than half of those with severe CTE.

Neurodegenerative disease is the most common fear and concern related to CTE, but there are some serious questions in the data about the severity of CTE’s cognitive impact.

Of 84 donors who submitted standard informant reports and had severe CTE, 71 donors (81%) reported symptoms of dementia in their final year, but only 26 were diagnosed with Alzheimer’s disease or Parkinson’s disease (31%).

This is significant, because there are many other factors that could lead to symptoms of dementia, such as vascular disease, depression, and substance abuse.

Keep in mind, 46 donors (56%) reported depressive symptoms. Additionally, 41 of the 84 donated brains in this group reported substance abuse (49%), with 31 donors (38%) reported alcohol abuse and 23 donors (28%) reported “Other” substance abuse. Finally, remember the average age of death for all brains with severe CTE was 71, with half of the donors dying between the age of 64-79.

So, are the symptoms of dementia caused by CTE, or do substance abuse, depression, and other issues in old age cause these symptoms?

Age of Death and CTE

The median age of death for the 133 donors with severe CTE was 71 years old, with an interquartile range of 64-79. This means less 33 of these donors (25%) died before the age of 64 and 33 donors (25%) of donors with severe CTE lived at least 80 years. According to the CDC, the average life expectancy for males in the US is 76.3 years. Therefore, there is not a dramatic difference in the average age of death of donors with severe CTE than the general male population.

The median age of death among 44 donors with mild CTE was 44, with an interquartile range of 29-64. In this study, the age of death among donors with mild CTE appears younger than those with severe CTE because 12 of the 44 donors with mild CTE (27%) died of suicide and 9 of these 44 donors cause of deaths were categorized as “Other.”

Only 7 of the 44 donors with mild CTE (16%) died of neurodegenerative diseases.

CTE Among Position Groups

One of the tables broke out the donors by position groups. Offensive and defensive lineman were the most common position groups in the sample, and they also had a higher rate of sever CTE than other position groups. This information is not entirely surprising based on other research.

However, the sample included two kicker/punters, both of whom had mild CTE.

The kickers had CTE? But you cannot hit the kicker in football!

This statistic alone makes me wonder if there are non-contact activities of football (and activities more common among lineman) that contribute to developing CTE. The limited contact to punters and place kickers should raise red flags here.

Other Interesting Findings

• Of the 111 donors who filled out informant reports, only 4 were diagnosed with motor neuron disease (ALS/Lou Gehrig’s Disease). When Tim Shaw announced he had been diagnosed with ALS, many wondered if football contributed. However, this sample suggests ALS is not a common effect of CTE.
• Many who have followed the stories of CTE, including several family members and myself,  have speculated use of anabolic steroids may have contributed to the development of CTE. Of the 111 donors who submitted informant reports, only 4 reported anabolic steroid abuse. My gut tells me that respondents underreported, but none the less, the numbers do not suggest steroids influenced CTE in this sample.
• Of all 177 brains studied, only 3 included donors who never played beyond high school. All 3 were classified as mild CTE. No details were provided on their symptoms.

Alternative Studies (With Control Groups) Remain Largely Silenced

While most of the stories about mental health and football have a grim outlook on the sport, there are other studies out there that have received less attention.

Wisconsin Longitudinal Study – On July 3, 2017, JAMA Neurology published a study by a group of statisticians and medical professionals based in Philadelphia, titled “Association of Playing High School Football With Cognition and Mental Health Later in Life.” The study, led by Sameer K. Deshpande and Raiden B. Hasegawa, is based on data from the Wisconsin Longitudinal Study, which followed 10,317 randomly selected Wisconsin high school graduates from the class of 1957.

From this sample frame, the researchers could gather all the necessary participation and health data from 2692 men, of whom 834 played high school football (31%) and 1858 did not (69%).

(In recent years, participation in football is calculated at 6.67% of all high school students, including female students. I cannot find exact numbers, but this likely means 13% of all male students play football today.)

Of those in the study, there was no statistically significant difference in composite cognition between former football players and the control group, and the former football players showed significantly fewer depressive symptoms than the control group. There was also no statistical difference in the rate of excessive alcohol consumption between former football players and the control group.

Lehman, et. al – In 2012, a study of NFL player pension data from 1960-2007 found that players who were in speed positions had an elevated rate of neurodegenerative disease than the general population, whereas non-speed positions did not have a higher rate than the general population.

Still, only 27 of the 1116 players studied (2.4%) had a neurodegenerative disease listed as an underlying or contributing cause of death on their death certificate, compared to 207 players who died of cancer (18.5%) and 466 players who died of cardiovascular diseases (41.7%).

Mayo Clinic – In January 2017, the Mayo Clinic released a study of high school athletes from 1956-1970 which found that despite a higher prevalence of reported head trauma, former football players did not exhibit a higher propensity for neurodegenerative diseases than other former athletes. This built off their 2012 study that found former football players had the same risk of neurodegenerative diseases as members of the marching band and glee club.

For parents who are concerned with the risks of their children playing football, I recommend you take some time and watch award-winning neurosurgeon Uzma Samadani’s address to high school football coaches in Minnesota and Texas on YouTube.

Samandani sent out a survey to 155 neurosurgery department chairs around the United States asking about their athletic careers. The most common response? Of the 62 respondents, 35% played high school football, at least 10% played in college.

Taking Good Risks

Adolescence is a turbulent stage of development with a number of challenging decisions. Every fall, at freshman orientation, I offer the same advice: Take good risks.

Some of these risks are easy to explain. Take the tougher class. Try out for the school musical. Ask him or her out on a date. Apply to your reach school.

To me, football is a good risk as for young men as well.

It hurts to hear parents say they will not let their sons play football for fear of head injuries because of the unique experience of the game. I participated in baseball, basketball, swimming, and track & field teams in my younger years, and I know these sports offered benefits as well. However, nothing compares to the experience of playing football.

Football is one of the last true team sports, where all participants must work in synchronization. There is a special bond among teammates and a different form of resiliency and grit you build from playing the game. You are more confident under pressure when you’ve already played before a crowd of 5,000 people. Finally, I feel believe there is value in giving teenage boys a controlled outlet for their aggression.

Injuries occur in high school football, and some players do sustain concussions. However, the risk of long term neurological issues is less than those who play in college and the NFL. In addition to the higher number of accumulated hits among college and NFL players, the difference in athletes’ size and velocity makes the high school game safer.

Not all boys want to play football, but I do not see the value in holding back those who do.  No matter how much we try to protect our students, there are risks of sustaining concussions and CTE in many activities.

In my ten years as a classroom teacher, the student who missed the most class time due to a concussion sustained the injury from a car accident. The second longest concussion recovery? A student in the stage crew fell off a ladder setting up the spring musical.

Last fall, we had two concussions across freshman, JV, and varsity football. This is not by coincidence – we work hard to improve blocking and tackling instruction, and we do not have the “live” contact drills that would have been common when I played.

Still, we held spring workouts this year with five players on concussion protocol. Two were sustained playing rugby and two from playing lacrosse. The final player took a fastball to the head in a June baseball game, and will not be cleared to play this season.

Thankfully, due to modern studies of concussions, these athletes receive better treatment than they would have a generation ago had they reported a “bell-ringer.”

Experts also say that research on the accumulation of subconcussive impacts is not conclusive. While many have hypotheses, more research is needed. For the sake of comparison, preliminary research also warned that cell phone usage may be linked with brain cancer fifteen years ago. Those hypotheses are, at best, contested today.

Sometimes, concerns about the safety of football are reasonable, and I understand when parents prohibit their son from playing if he has a history of concussions. Other arguments sound more irrational.

Another friend and colleague chastised a fellow teacher who said he was unsure if he would let his boys play football, saying “You have a college degree! You can’t let your boys play football.” When I responded that I did not think playing football inhibited the careers of Dwight Eisenhower, John Kennedy, Richard Nixon, Gerald Ford, or Ronald Reagan, the colleague said, “See, only the dumb presidents played football!”

Walking Away, Someday

Today, I began my 18th football season – I played for eight seasons and am starting my tenth season as an assistant coach. I do not know how many more seasons I have left.

In January, I met an amazing woman and an inspirational educator who works with immigrants in the School District of Philadelphia. Two weeks ago, she agreed to marry me, and we look forward to starting a family in the coming years. I just began a doctoral program at Temple this summer, and already need to work around scheduling conflicts with football.

Someday, I will walk away from football, but it will not be out of fear for my players safety. Until then, I will enjoy each Friday under the lights.

While unnamed sources have said John Urshel walked away from the game last week because of the most recent report on CTE among NFL players, Urshel never mentioned these fears in his own statement announcing his retirement.

Instead, he mentioned the opportunity to take classes that are only offered in the fall and starting a family with his fiancé.

Maybe the recent McKee report and his concussion last season factored into his decision, but I doubt this report alone drove him to abruptly quit. The most recent findings are not drastically different from when Urshel explained his rationale for still playing two years ago, or spoke out this January about his love of the game. He has spoken on the subject many times, and has yet to personally voice his concerns.

There are often players who realize it is time to move on just before he start of a new season. Urshel is younger than most, but I get the impression, considering his achievements in academia, that he is running towards a new direction than running away from a previous chapter.

I highly doubt John Urshel will ever go hungry in his lifetime, and true to stereotype, that is important to us linemen.