Clinical Lifestyle Public Health

A League of Randomized Clinical Trials

Frontline recently reported on data released from Boston University and the Department of Veterans Affairs demonstrating that out of 91 former National Football League (NFL) players, 87 had Chronic Traumatic Encephalopathy (CTE).  This degenerative brain disease is believed to be the result of repetitive head trauma, and can lead to memory and mood disorders. [1] It is unclear why the disease develops in some players but not others.

The findings of the above study come with several limitations.  In particular, the gold standard for CTE diagnosis is examination of brain tissue postmortem.  The data comes from players who were concerned during their lifetimes that they showed symptoms of the degenerative disease and arranged, upon death, to donate their bodies and brains for analysis.  As a result, the prevalence of CTE suggested by the data may be skewed due to selection bias.  The brains examined post-mortem came from athletes already concerned about CTE because of their clinical symptoms, making it much more likely that the investigators would find evidence of the disease.  The ongoing work at Boston University and the Department of Veterans Affairs is a retrospective analysis that cannot determine the cause of CTE.  It is important, however, for the identification of factors that are correlated with the disease, which may spark more interest and lead to more focused research on the topic.  Even so, the disease was present in 96% of those who were tested.  This finding is both remarkable and eye-opening.  It demonstrates a real concern for athletes in contact sports like football.

Organized football poses a risk of concussions.  Chris Borland was a college linebacker and All-American drafted into the NFL in the third round in 2014. Although he only had two diagnosed concussions, one during eighth-grade soccer, and the other playing high-school football, he estimates that the actual number is closer to thirty. On March 13, 2015, Borland retired from the league via email. [2] He has since described the move as preventive and outlined his determination to prevent the degeneration of his own brain.  The NFL is aware of the risk posed by concussion and has focused on decreasing the rate of this injury.  In their 2015 Health & Safety Report, the NFL published a thirty-five percent decrease in regular-season concussions from 2012. [3] According to the data shared with Frontline, however, forty percent of those determined to have CTE were offensive and defensive linemen, players who have repetitive, sub-concussive hits on nearly every play. [1] This suggests that recurrent, lower-intensity blows may also lead to CTE.

Chronic traumatic encephalopathy is not unique to football players. It can be seen in other athletes, military veterans, epileptics, abuse victims, and circus performers who are shot out of cannons. [4] The scientific and medical communities should not delve into the controversy of any alleged cover-ups as discussed in the Frontline documentary A League of Denial. [5] Rather, our focus should be on furthering research, because our understanding of this condition is still in its infancy.

Rates of CTE in the general population or even in the professional football community have not yet been established.  The gold standard of scientific experimentation, the double-blinded, randomized controlled trial is not an ethical or practical possibility in this case.  Players without symptoms of CTE must be analyzed to allow for characterization of healthy persons as well as sub-clinical disease.  This may help identify why some people are afflicted with the condition and not others.  Those who suspect they may have CTE should be granted medical care and follow-up to help the scientific community better understand the degenerative progression of the disease.  Research should not be limited to professional athletes, as college and even younger athletes may be at risk of developing CTE.  It also should not be limited to football, as head trauma occurs in many sports.  It is important for professional organizations and sports fans to support research and efforts to implement relevant safety measures to preserve the health of their favorite athletes and to enhance the quality of the sports they enjoy.


  1. Breslow, J. (2015, September 18). New: 87 Deceased NFL Players Test Positive for Brain Disease. Retrieved September 20, 2015.
  2. Fainaru, S., & Fainaru-Wada, M. (2015, August 21). Why former 49er Chris Borland is the most dangerous man in football. Retrieved September 20, 2015.
  3. 2015 NFL Health and Safety Report. (2015). Retrieved September 20, 2015, from
  4. Hanna, J., Goldschmidt, D., & Flower, K. (2015, October 11). 87 of 91 tested ex-NFL players had brain disease linked to head trauma. Retrieved October 12, 2015.
  5. Frontline. (2013). League of denial: The NFL’s concussion crisis [Motion picture]. United States: PBS

Featured image:
Football 10.18.08 by Mike Hoff

Clinical Opinion Public Health

It’s Time to Take Responsibility for our Unimmunized Patients

There is an old parable about a tree that falls onto an old dirt road in the forest. On the day the tree falls, the daughter of a rich king is passing through the forest in her carriage. The carriage runs over the tree, loses control, and crashes. A passing lumberjack sees the overturned carriage and carries the princess to safety. Her father, the king, throws a great celebration in honor of the lumberjack, and rewards the hero with riches.  In the next village, another tree falls on the road.  In this village, the lumberjack sees the fallen trunk and with great difficulty carries it off of the road.  The princess never crashes and she continues on her way, none the wiser.  A hero all the same, there is no celebration and no reward for this lumberjack.  This allegory wins no awards for its subtlety.  While life-saving and innovative treatments are often lauded by the general public, the praises of preventive measures often go unsung.

Vaccines are considered among the safest and most effective public health interventions. [1] There is no dispute among the scientific community, and repeated peer-reviewed studies have detailed the value of vaccines as preventive health measures. These studies collectively support the conclusion that the benefits of using vaccines to minimize illness outweigh the potential risks.  It is precisely because of the overwhelming success of immunizations that people have little or no personal experience with diseases like smallpox, or chickenpox, or polio.

Parental autonomy suggests that parents have the right to raise their children as they see fit.  As a result of this benign belief, however, more young parents believe that vaccination should be a choice. [2] To combat the anti-vaccination movement, health care providers have traditionally relied on their role as medical experts and discussed the scientific data, expecting patients to trust in evidence-based medicine. But the inability of overwhelming evidence to quell controversy and resolve debate has led to greater polarization—biased reasoning has made discussion counterproductive and has led to the intensification of beliefs for many of those opposed to vaccination.  As a result, there are groups of under-vaccinated children which increase the risk of an outbreak in the general population. [3]

There are patients who will continue to refuse to accept research and statistics, even when presented by a trusted family physician. These patients have fallen victim to misinformation and fear-mongering. Their concerns include side effects, immunization schedules, financial incentives, and “Big Pharma”, but more broadly represent suspicion of biomedical research and healthcare providers.  [1]

Physicians often suffer from the curse of knowledge—an inability to recall the lack of understanding that came before learning a new concept. This may play a role in the notoriously poor communication skills of doctors.  For example, watch a third year medical student discuss a clinical subject with a first year medical student and notice the difference in the use of clinical jargon.

Learning how to read a research paper, understanding how and why the study was performed, and recognizing the implications of its conclusions are skills taken for granted by those in the scientific community. These skills take years to learn, yet clinicians reference data and statistics to their patients indiscriminately.  If we want patients to trust us, we have to admit when what we are doing is not working, and be willing to change. For some patients, citing facts and figures is not an effective tactic.

It can be easy to vilify those opposed to vaccination, but new parents continue to be drawn to the movement every day. In a culture of blame, when there is an outbreak of an infectious disease, we instinctively search for someone to condemn and hold culpable. We would be better served by identifying what makes individuals skeptical and how we can change misconceptions and behaviors. The issue at hand involves trust.  Some patients will not trust what we have to say as providers. We have to consult the experts—we must refer them to their grandparents.

Grandparents can discuss the ominous nature of diseases that many of us, due to vaccination, are not frequently exposed to.  They can explain what it means to have a cousin under quarantine or a sibling living with the complications of an infectious disease.  They can express what it means to lose an infant child to a vaccine-preventable illness. Anti-vaccination parents have had the impact of their decisions mitigated due to many years of previous vaccination and herd immunity—a community’s general protection from disease because of a high proportion of immunity in its members.  It is time for us, as medical professionals, to admit that we must change our tactics.  Some patients may not understand the consequences of many of these infectious diseases, but I bet their grandparents do.


Featured image:
Clipart edited by Ilya Aylyarov