In League of Denial, the 2013 book chronicling American football’s brain-injury crisis, there is a throwaway comment by Warren Moon, the former quarterback, to his agent, Leigh Steinberg. Despite the implications for his business, Steinberg had lobbied hard in the mid-1990s about the dangers of concussion. “You’re probably right,” Moon told him, “but I wish you’d shut up.”
The exchange represents a neat microcosm of the dilemma facing contact sports as they come round to the reality of head injury and its repercussions. Nobody wants any of this to be true, which means a form of double-think has lingered not only among the game’s authorities – for whom such an attitude may yet prove a case of negligence – but among all of us.
This week’s news, including the revelation that England’s 2003 World Cup winner Steve Thompson has been diagnosed with early onset dementia, is shocking because it sweeps away what is left of the old paradigm that, yes, head injury is never good, but then this is sport, which is. So many questions are raised, but perhaps the most unnerving aspect is the degree to which answers remain just out of reach, including the most profound of all – can a sport continue, knowing that even a tiny number of its players might suffer long-term problems of the most harrowing and debilitating nature?
Just asking that question creates an existential threat to that sport. The ethical importance of the discussion is paramount, but how to have it while still assuring prospective players – and their parents – the vast majority will be safe? It places great onus on administrators, whose options fall into two familiar policy areas, those of prevention and treatment.
The second is much easier territory than the first, but as far as efficacy goes the key interventions can come only from science, which, as we know from recent events in the wider world, must move at its own, frustratingly slow pace.
MRI scans are akin to taking a picture of the outside of a building that is on fire inside
The holy grail for collision sports is a bio-marker that will test for brain injury immediately. Some in science, and in rugby, are excited about imminent breakthroughs, but others advise patience. Eighteen months ago, there was talk from within the RFU of a “game-changing” bio-marker in time for last year’s Rugby World Cup. That proved a false hope, but the balance of opinion sought by the Guardian suggests a definitive test for brain injury, certainly if it is to be deployed at pitch-side, could still be some years away.
Other measures are closer to hand, including improvements in the technology of brain imaging. The magnetic resonance imaging (MRI) scan players for so long have assumed to be the gold standard will not pick up the sort of damage suffered from mild traumatic brain injury. MRI scans came back as normal for all of the diagnosed players. It is akin to taking a picture of the outside a building that is on fire inside. The fire will not show up in its early stages.
The diffusion tensor imaging (DTI) scans that confirmed the damage in the players’ brains are of a more sophisticated technology. They can detect what is going on inside, but they are expensive. If rugby can find a way to use the hardware in conjunction with the universities that house it, the idea of a “brain MOT” for all players becomes not only real but one of the most compelling of the propositions put forward by the players in their “15 commandments”.
Another improving technology measures impacts. This season, Harlequins and Gloucester have adopted a device called Protecht, a chip in the mouthguard that is of the next generation of such gauges. Technologies like this should be rolled out as widely and swiftly as possible.
Taken together, a picture may start to emerge of what is happening to players’ brains in the elite game and a more informed policy developed for their management. But here lurks the danger of what we might discover. If it were to materialise that a typical rugby match contained multiple instances of brain damage, however small, what then?
And so we turn to prevention. This is where rugby’s dilemmas become treacherous. Because the only way to make rugby safe is to stop playing it. Or – and many would contend it amounts to the same thing – to remove its collision element altogether.
That remains too extreme an idea (for now anyway), but if we conceive of a safety scale with that scenario at one end, then the status quo at the other and all points in between represent degrees of accepted risk. As we try to move rugby along the spectrum towards the safe, is there any notion of when we might stop, of when rugby might be declared safe enough? However far we go, a next step will always present itself, until that endpoint is reached, a game without tackling.
Concussive head injuries in rugby union – a timeline
1975 Rugby union first seriously discusses the issue of concussive head injuries, at a medical conference hosted by the Irish Rugby Football Union and attended by senior administrators, coaches, players and doctors.
1977 Medical Advisory Committee of the International Rugby Board (now World Rugby) established and the introduction of a three-week stand-down rule for any player diagnosed with concussion.
2004 Sports Concussion Assessment Tool (Scat) developed as standardised assessment tool for acute concussion.2009 IRB adopts policies related to concussion according to standards of the Concussion in Sport Group (CISG).2011 Three-week minimum stand-down is reduced to come into line with CISG which sees a six-day stand-down and graduated return to play protocols.2012 Pitch-side Concussion Assessment (PSCA) adopted from August including five-minute temporary substitution. Dr Barry O’Driscoll resigns from the IRB in protest at the PSCA as he says it “trivialises” concussion. PCSA allows players to return to action if they are cleared by doctors within a five-minute assessment. They must pass a series of questions and a balance test.2013 George Smith is knocked out during Australia’s third Test against the Lions in the fourth minute. After assessment by three doctors, he returns to the field. He trains all week and is picked on the bench for the Brumbies, sparking questions about assessment protocols.2014 In February the IRB announces the setting up of a specialist independent advisory group on concussion. PSCA is strengthened and extended to be renamed as the HIA assessment, it extends the temporary substitution period to 10 minutes with the memory test strengthened and the balance test altered and increases viewing options for doctors of incidents on field.2015 Public outcry after George North returns to pitch having appeared concussed in match against England – and is then knocked out again.2016 World Rugby completes a large-scale study on risk factors for head injury in elite rugby. Research suggests new ways of looking at game are needed as tackler is at greater risk of head injury than the ball carrier.2017 World Rugby introduces new high tackle sanctions. After an initial flurry of cards dies down, experts such as Willie Stewart, who sat on World Rugby’s Independent Concussion Advisory Group, criticise authorities for not enforcing sanctions.2019 World Rugby instructs the French Federation to commence trials on a new legal tackle height at the waist in the community game. Early signs are encouraging but Covid-19 forced the trial to be paused. Claire Tolley
Photograph: Michael Steele/Getty Images
So far, focus has centred on the height of those tackles. It feels like a typically flawed policy has been adopted of simply sending players off for high tackles, essentially shifting the blame on to them, rather than implementing fundamental changes in the rules. More progressive ideas are being trialled in French community rugby, whereby a new tackle height has been established at waist level. World Rugby are excited by the early results, but Covid-19 has put that on hold.
Whether these steps will have any meaningful effect is questionable. Using World Rugby’s own data, it is possible to estimate how much of a reduction in head injury we could expect, theoretically, if every upright tackler were turned into one bent at the waist. The answer is just over 8%, which would be less than transformative.
Other tweaks of the rules will be trialled, as they always have in rugby union, all with compelling arguments against, as well as for. Another driver of rule change is the pursuit of entertainment, to make rugby “more attractive”. Those ideals of entertainment and player welfare are almost always in opposition to each other, which puts rugby on another sliding scale without a target.
If fixing the game is fiendishly difficult, another option might be to reduce exposure to contact. This idea is gaining traction in American football and our own football. To limit contact in training is a simple measure rugby might introduce, but it is likely most of the gains there have already been effected by more sophisticated training regimes.
In 2016 an open letter from 70 doctors called for a ban on tackling in schools. The reaction was uproar, but expect this proposition to come again. If cumulative exposure to impacts is a factor, which seems certain, those early years could tip the scale against players who go on to have long careers. Alix Popham started at the age of four and has no doubt his condition now is a function of his length of time in the game. Then again, Thompson did not start playing until he was 15.
The pattern feels familiar at this torturous juncture in rugby’s history. So much confusing evidence, so many conflicted motives and emotions. There are times when anyone who loves this beautiful, benighted sport does want to scream “Shut up” to the whispers of doom. All they want is to enjoy it again unconditionally, but there is a graver directive now. It must be negotiated deftly if there is to be any hope of a return to happier times.