Part of the above title is from the decades old popular tune by the late great Waylon Jennings, “Don’t Let Your Sons Grow Up To Be Cowboys,” which had a message its all own about the rough life and that reality was not as romantic as portrayed in the American myth of the cowboy and perhaps about his own life as well as a hard living, hard drinking country entertainer. I always wondered growing up what effect his not getting on the plane in the 1950’s with “The Big Bopper” and the equally great late Buddy Holly, that crashed and killed them, had on Waylon Jennings, the fact he accidentally avoided death. I thought even as a kid his music had a certain wistful, depressive undertone to it, rivaled only by a few other such singers and lyricists. My apologies to his spirit for commandeering his song title partly for this piece.

Since the death by shotgun blast aimed intentionally at his chest, by Dave Duerson over a decade ago, a former lineman for the St. Louis Cardinals (back then), there has been much controversy over the effect of head bashing and cranial trauma on football players, most of it focusing on the effects by the time one has reached the professional ranks as a young and pre-middle aged adult in one’s late 30’s when most pro footballers retire. Lineman, as I understand it, tend to play longer and have longer careers than running backs and maybe pass receivers who run, are more mobile in the specialty positions and far more likely to suffer “career ending” knee injuries much frequently earlier in their careers.

Dave Duerson knew something was badly wrong with him mentally and likely cognitively. He was reported to have complained of headaches, depressions that he could not shake, memory problems, awareness that his intellect was failing him, mood changes, i.e., anger outbursts that he could explain or control, but most of all apparently a growing persistent, unshakeable preoccupation with suicide. He apparently revealed almost none of this to close friends, associates, family, and I like everyone else have no idea whether he revealed these self witnessed changes to his physicians. In any case, he stunned the sports world when he committed suicide, left an explanatory note that he mandated his brain be donated to neurological science and studied for what he felt was wrong with him. It was immediately clear that his placement of the barrel of the shotgun he used to kill himself was intentionally placed on his chest to preserve his skull and brain for scientific study. His courageous, if one can use that term as I know there are many opposing viewpoints about the act of committing suicide itself, but sad death, put the football world on notice that nothing had before, that something bad was going on with head injuries and possible or likely later in life serious repercussions like dementia and mental changes. The NFL had had by that time an ongoing study following players after retirement and had an investigational neurologist heading up the long term follow up study. But it gradually became enmeshed in horrendously vitriolic controversy as being inadequate, having conflicts of interest with the head of the study being paid and retained by the NFL and perhaps not open to enough peer review, scientific scrutiny. The NFL maintained relative silence on the issue but the uproar grew and grew especially in the neurologic scientific, brain research communities and the head of the program resigned or was fired (who knows how these work behind closed PR doors, especially when they say the standard exit euphemism of “He wanted to spend more time with his family”).THe study commissioned was thoroughly revamped, restocked with different personnel from many disciplines and made independent of the NFL. The sports media speculated on the supposed reactions of the team owners’ whose buckets of gold could potentially be threatened etc.

All of this worry about head injury potential in the “contact sports,” was also buttressed in the minds of the medical community and in the military because of the rapidly growing numbers of brain damaged veterans returning from the Middle East wars since we invaded Iraq in 2003. The new tactic of guerrilla warfare of utilizing the deadly, oh so portable and easily concealed, powerful “improvised explosive devices,” or “IEDs,” was forcing the science of traumatic brain injury to the forefront of American neuromedical research and treatment resources. These veterans were coming back as new incredibly sad human anomalies, as more or less young demented persons. They also typically had/have the personality, mood and executive skills deficits that Dave Duerson saw in himself, imagined his future and decided life was not worth living and decided suicide was the best alternative for his family and himself! The head trauma and brain damage of contact tackling football had an ally, the veteran population cohort of IED brain damaged persons in the tens of thousands, far more than pro football may every produce in its present form. So what is the military’s possible tactical alternative to using human soldiers who will get brain damaged? Robotic soldiers, science fiction come true. If their brain CPUs get damaged, just put in a new replacement unit and back into battle. The robotic mechanized warrior soldiers of Star Wars and the space war genre movies of the last 30 years may very have predicted the future of international warfare.

So the rapidly growing realization in military medical and concomitantly civilian neuromedical circles that “Houston we have a problem,” helped to keep the NFL story and scandal alive, would not let it die, even with the repaired study commission, and the over $700 million settlement the NFL paid out of players already impaired approximately two years ago. If you do not know, that settlement was an open ended one; meaning that the next wave of impaired damaged players can sue and collect, and the next, and the next and so on. The financial penalties may kill pro football in our culture within the lifetime of present young adults just because of that, unless the revenues sources increase by say a thousand fold somehow. Will Fox and ESPN and NBC and CBS be willing to pay the NFL a billion dollars to broadcast each game? Will tickets to the stadia have to be tens of thousands of dollars each? The economics will be the deciding factor in my view; they always are when our nation cannot face important social dilemmas that are true dilemmas with no easy answers, and when all the possible answers require undesired lifestyle changes, considerable cost, or increased taxes, etc.

Finally two years or so ago, the findings came more into focus and it became clear that the more concussions, blackouts and such that a player had had during their career the more likely they were to develop worrisome CNS based (central nervous system, meaning the brain and all it does). Speculation ran rampant, was this why Johnny Unitas deteriorated over the later years after his retirement and basically died of complications of out of control alcoholism? More suicides followed, not many but in the light of increased awareness, each was like the bell of doom slowly but inexorably tolling for the future of football as it is known now. Media and the NFL talked of already long ongoing research into making football helmets more safe, crash worthy  and protective of the brain. Emphasis ramped up on protecting the quarterbacks. Head to head ramming torpedo like tackles which had been banned for several years began to be much more frequently penalized and players who were adulated for their rough style of defensive tackling, especially pass defenders and line backers to a lesser extent and a few linemen were suddenly socked with BIG monetary fines to try to start to moderate another part of the game that was felt to be possible be a malignant “risk factor,”

In the last 2 or 3 years, I am not sure as I do not follow football since since my childhood when I did religiously watch pro games on Sunday with my late father, who was from Texas, had played football, and was literally in his day a truly big player built for the line. So football was like “religion” to him like many other folks from the South and Southwest so the image goes, but especially Texans supposedly. But I never played, I was smaller and just not interested as I was a geek-intellectual-“brain” as kids called me from a very early age. My father accommodated to it nicely and humorously and warmly called me among other nicknames, “Perfesser,” for Professor. (My family was big on nicknames, we all had several and they were always used as terms of endearment I am happy to say.) So that is my disclaimer about football, I was alway neutral or as I called it borrowing an expression from another language, “fifty-fifty” about it in general. I even poked fun at myself about football. I had attended the University of Michigan for the majority of my undergrad studies, and for medical school. So for a few years afterward I would watch the Rose Bowl if Michigan was the representative from the then Big Ten Conference. Michigan always lost if I watched the game so after a few years I stopped watching football altogether, ignored all the “Bowls,” and explained it by saying jokingly by stating that if I watched a team I was inclined toward, almost always the underdog since I knew nothing about standings or teams etc., they and Michigan, “always lose because I am a football jinx.”

But a recent more ominous research study emerged early this year in January published online to “get it out there sooner,” I think because of its significance that made me rethink football altogether and ‘get off the fence.’  It was succinctly titled: “Age of first exposure to football and later-life cognitive impairment in former NFL players.” It emerged online in the journal Neurology and clearly had been peer reviewed, and vetted carefully. The lead author was Dr. Robert A. Stern MD, whose email was revealed in the abstract as: bobstern@bu.edu if readers in the scientific world or others would wish to contact him. The other authors were: Julie M. Stamm, Alexandra P. Bourlas, Christine M. Baugh, Nathan G. Fritss, Daniel H. Daneshvar, Brett M. Martin, Michael D. McClean, Yorghos Tripodis and of course Dr. Sterrn. To the reader, in the abstract the credentials of the other co-authors were not listed so this is why I have not included them after the co-authors’ names to make sure no one thinks that is some kind of subtle slight or dig at them. This study was quiet disquieting to coin a bad phrase.

Forty-two former NFL players who were retired and no longer playing so that would not be a “confounding variable,” (some ongoing factor in the study subjects that muddies the waters of observation so badly one cannot tell what is causing what…). They were ages 40-69 and were matched by age and divided into two groups based on their age of first exposure (called in the study “AFE”) to tackle football with the dividing line of age being younger than 12 years of age and 12 or older. They were given a battery of several tests of cognition and intellect. All the tests were, believe me, thoroughly reliable, accurate and reliable through decades of use, revisions and the process of “norming,” which is periodically gathering what is called nowadays “Big Data” figures on test results on large numbers of subjects and making sure they still accurately measure what they are supposed to.

The results were very somber, sobering and not at all good for the future of football even football in its proud and near universal male culture of football in America of boys starting to play as young as age six years in what is called “Pee Wee” football (I may be wrong on that term as that may be for a slightly older age range, I am not sure as I am not in this world…) Coincidentally, as a humorous aside, through one of my granddaughters I just learned there is a new younger rank of Girl Scouts that did not exist years ago during our two crops of daughters. They are the “Daisies” and start at 5 years old apparently. And here all this time, I though the youngest were the venerable “Brownies” and my favorites brown berets that I always thought were so cute.

Back to football…The bad results on the football players were really bad. The younger you were when you started playing “tackle football” which starts sometime after the first Pee Wee by age 10 or 12 or somewhere in there,  (forgive me if I am making a factual error about the name designation or actual age at which tackle playing starts, the worse the effects as an adult on reading levels, memory impairments, “executive functions” (decision making, abstract judgments, more sophisticated kinds of higher level thinking that require integration and understanding of many kinds and levels of more abstract information), verbal IQ, etc.

The study abstract summary ended with the diplomatically worded statement: “If replicated with larger samples and longitudinal (follow study subjects over long or longer periods of time, e.g. right from retirement in their 30’s up to elder years) designs, these findings may have significant implications for safety recommendations for youth sports.

I will be more direct about this.  Adequate safety measures in my view as a psychiatrist who came from neuroscience in my college years, would need to be FAR more stringent than what we have or even envision now. Better helmets will not be nearly sufficient in my view. The  time limits for keeping players out for recovery after they have had a concussion should be much longer than even now. Youth football, even in the high school years, may have to drop tackling and head contact altogether. Each adult college and/or pro player may have to sign a waiver that they know, acknowledge and assume full personal responsibility for the risks, and will NOT hold the NFL, the teams or owners responsible for deficits they may or will suffer as a result of playing real rock ’em, sock ’em pro football. If further studies show as it is feared by untold numbers in the interested neuroscience/neurology worlds, that the incidence after 20 more years of longitudinal follow up is much higher than the puny data we have now implies, then I can foresee real problems for the sport. I would expect prices of everything to go up associated with the sport, players will not be able to get insurance without exclusions regarding this kind of delayed later in life CNS damage, or have to pay insurance premiums they could not possibly afford, or all players and the owners would have to start and maintain a huge Social Security type ahead of time saving program for their eventual dementia/psychiatric care, with big chunks of their paychecks being taken out just like income tax, on a mandatory basis, and maybe their flashy absurd lifestyles would have to scale downward toward wiser reality. Or the sport would have to be played with such absurd safety measures like people in those blow up balloon suits and just bounce off each other all over the gridiron. That is not what fans want to see. Professional football is still, along with wrestling, boxing and mixed martial arts, America’s Roman Coliseum where blood, injury and gore were the main elements of the entertainment value.

And having mentioned the other head bashing sports, what will happen to them. We have long known that boxing regularly produces brain damage. Joe Louis became very sadly demented. The revered Muhammed Ali many years ago was so impaired from his likely concussive brain damage that he had heart wrenching difficulty physically climbing the ladder and lighting the Olympic torch. Cartoons have had for at least since the 1950’s the sad buffoon of the over the hills boxer who stutters, shuffles and is not bright. A sad comment on our culture that still idealizes violence not matter what the cost but so do all of the male cultures.

I think it is safer to be a Brownie Scout by far.