Part IV: The Life and Contributions of Bennet Omalu MD

NFL commissioner Paul Tagliabue came under intense pressure from the press on the issue of concussions and football safety soon after.  As a pressure release valve, the NFL announced a scientific study of its own, and the Mild Traumatic Brain Injury Committee (MTBI) was formed.    The committee was to be headed by Dr. Elliot Pellman, the New York Jets team physician.  Pellman was not a neurologist or an internist, and, according to reports, had no knowledge of the extensive literature on concussions up until that point, despite it being a focal point of football medicine.  Despite these educational shortcomings, he treated Al Toon, a standout Jets wide receiver, for multiple concussions until the head injuries forced his early retirement.  Far from having an impressive academic educational pedigree, (Pellman attended medical school at the Universidad of Autonoma de Guadalajara, in Mexico), he was a rheumatologist by training.  Pellman and his committee set out to define the meaning of the word concussion and then instituted a battery of neuropsychological tests to monitor for concussions league wide.  The committee was dark for nine years afterwards, not publishing any findings until 2003, when they produced a series of studies ending in 2006, almost a decade after initiation of the committee.  The committee concluded there was no evidence for long term brain damage in players who suffered concussion, and that it was safe in many instances to return a player to the game on the same day of a concussion.  It also concluded that players suffered no permanent ill-effects after multiple concussions according to their studies.  To improve safety, the committee focused on ways to develop a helmet capable of limiting or preventing concussions, with the latest technology.  The committee’s work was not respected in the medical community, nor in the community of common sense, and their conclusions drew enormous criticism.  They were seen as mere lackeys to the NFL establishment.  Their take home message “Football is safe and now that we have proven what we already knew, we can all go back to enjoying the game and stop worrying.”    The committee, in response to intense criticism, was eventually disbanded in 2010, sixteen years after formation.

After Omalu published his ground-breaking case report in Neurosurgery in 2005, the MTBI committee immediately went on the offensive.  They wrote their own flawed rebuttal to Omalu’s paper that was also published in Neurosurgery, but in May of 2006, writing “We disagree with the assertion that Omalu et al.’s recent article actually reports a case of CTE in an NFL player.”  This is based on a “serious misinterpretation of the neuropathological findings in relation to the tetrad characteristics of CTE and a failure to take an adequate history.”  The editorial was penned by Ira Casson, Elliot Pellman, and David Viano.  The basis for their rebuttal is the comparison of Omalu’s description of what he reported in the brain of Mike Webster, neurofibrillary tangles in the deep sulci, and the findings commonly found by Corsellis et al, whose seminal work classified the basic criteria for Dementia Pugilistica, specifically:   Widening of the septum pellucidum, cerebellar scarring, degeneration of the substantia nigra with no Lewy bodies, and widespread neurofibrillary tangles in the cerebral cortex and brainstem, most prominently in the medial temporal lobe gray matter.  They believe these findings were representative of what would generally be found in a case of Chronic Traumatic Encephalopathy.  Through their collective ignorance, and what they failed to note, was that Omalu was saying “You are correct, this is NOT Dementia Pugilistica.  This is something different.  A different disorder.  We now know, through hindsight, that Dementia Pugilistica is a subtype of CTE.  It falls under the CTE umbrella, with CTE findings specific to boxers.  Corsellis had even described the same histopathological findings of DP in a chronically battered woman, who suffered years of physical abuse, on autopsy.  Football players, ice hockey players, and military veterans, who suffered shockwave damage from repeated exposure to firing military grade weapons, which Omalu was also the first physician to pathological describe, have become, neuropathologically, the classic examples of CTE.  What the MTBI committee mistakenly concluded was if the Omalu findings differed from what is classically seen in Dementia Pugilistic, the only form of CTE then known and fully classified, then Omalu must be wrong, this could not be CTE.  And if it was not CTE related, then Omalu must offer another explanation for the findings in Mike Webster, other than football.  The criticism that Omalu didn’t elaborate enough on the medical history in his first paper seems petty and nonsensical, since it was generally known that Webster was a retired football player with 17 years’ experience in the NFL playing in a known collision sport and with well reported tendencies to favor an aggressive style of play, leading with his head.  His mental and physical problems were also well publicized since his death.  Furthermore, they state they knew from their own research, that since Webster was an offensive lineman, they had a “Lower incidence of mild traumatic brain injury compared with other players.”   They also note Webster had no documented history of concussion or leaving the field of play after a blow to the head.  Without knowing it, the committee was digging its own grave. They went on to note Webster may have sustained brain damage in high school or college even, there was no way to know, which could theoretically clear the NFL.  Their reasoning was not only flawed but childlike.  Finally, in their piece de resistance, they urged Omalu et al to retract the paper, a serious request in the world of science with enormous consequences.  When he refused, what followed was a full-scale assault on Omalu, his character, his findings, and his credibility, as we will later see.

While important, helmets have more to do with preventing skull fractures than concussions.  A concussion occurs with a severe blow to the head, causing the brain to be impacted and then ricochet in the opposite direction and even rattle around the enclosed brain casing.  If two opposing players were both traveling at 15 miles per hour and collided, their helmets would protect their scalp and skull, but both brains would continue trying to move forward at 15 MPH despite the bodies that carried them grinding to a sudden stop.  In another fantastical example provided for emphasis, we know the Earth rotates on its axis at approximately 1000 miles per hour.  If the Earth’s rotation were to suddenly come to an immediate halt, all life on Earth would cease to exist in a fraction of a second, because our bodies would continue to move at 1000 MPH above the now still ground.  This is the reason why using the helmet solution to prevent or lessen concussions is a foundational fallacy.  Skull injury can be lessened or prevented, but not brain injury because the moving brain is still at risk for trauma when the body comes to a sudden stop in a routine tackle, head trauma or not.  The Pellman was correct when he said that concussions were an occupational hazard of the game.  Unfortunately, what he did not or would not acknowledge was that repeated high velocity head trauma, concussive, sub concussive, or asymptomatic, could do lasting, harmful damage to the player.  CTE is a cumulative phenomenon; repeated trauma to the brain, without the need to have documented instances of concussion, as in Mike Websters case.  Webster frequented multiple doctors after his playing career, desperately trying to explain his mood swings and lack of memory, his impulsive behavior and his chronic depression and severe insomnia.  When a doctor inquired if he had ever been in a car accident and Webster replied “Yes, 25,000 times,” that sad but humorful terse, answer embodies the essence of Chronic Traumatic Encephalopathy in a nutshell. 

CTE starts in the brain stem, the midbrain, specifically.  Because if you notice, in the cases that have now been published, the highest concentration or density of tangles is in the midbrain,” reflects Omalu.  He goes on to explain, “In traumatic brain injury, we know that the midbrain is the part of the brain that absorbs the largest amount of energy because it sits in the midline below the two cerebral hemispheres.  The cerebral hemispheres are slightly mobile.  The medulla oblongata (part of the brainstem) and spinal cord are mobile.  It’s been very well established that the midbrain is stationary and thus is the part of the brain that absorbs the greatest amount of shock.  That’s why when you see patients with concussion, they have brainstem symptoms.  The flatness, the distant gaze, the loss of consciousness, the dizziness, the vertigo.  It’s a brain stem phenomenon.”

 Shortly before Omalu’s debut paper in Neurosurgery, he received another brain to study.  Coincidentally, it was another Pittsburgh Steeler, Terry Long, who had played beside Mike Webster at right guard.  He was drafted out of East Carolina University in 1984, became a starter the next year for Pittsburgh, and retired in 1991 due to a constellation of injuries.  Long had become depressed and attempted suicide in 1991 apparently.  He later demonstrated impulsivity in personal and business decisions, mood swings, and intense paranoia, eventually isolating himself from the world.  Long had taken his own life by drinking a large volume of anti-freeze.  Although Omalu was not working at the time, the physician on-call notified Omalu that another NFL player was dead at an early age.  This time the technicians were all too eager fix the brain in formalin for him.  Omalu took to the microscope again, this time immediately.  Long’s brain showed the same deposition of abnormal, hyperphosphorylated Tau proteins and in the same distribution pattern, but even worse than Webster’s.  Once again, findings were not consistent with criteria for Dementia Pugilistica or Alzheimer’s disease.  Omalu had his second paper, and he was becoming an expert.

 At about this time, Omalu received a call from Dr. Donald Marion, a Boston Neurosurgeon and affiliated with the journal Neurosurgery.  “The NFL’s concussion committee has demanded a retraction,” stated Marion.   “The editorial board is considering their arguments to see if they are valid.  We put your paper through a rigorous peer review process, and we felt the scientific basis of the paper was sound.  That’s why we published it.  All I am asking is that you understand the seriousness of the situation and respond accordingly.  Focus on the science.  Don’t attack on a personal level.”  Omalu considered this sound advice, although it was difficult given his personality when attacked.  (Truth doesn’t have a side, Dr. Bennet Omalu and Mark Tabb, pg 188).

Others advised Omalu to take it seriously, that if his paper was retracted, it would have career altering consequences.  He could even be disciplined by the medical board or stripped of his license if intentional wrongdoing was found.  At the very least, his reputation would be discredited, and the NFL would no longer have to contend with him or his allegations.  Game. Set. Match.

“So, the NFL came for my jugular.  The civil war in Nigeria didn’t kill me.  Depression hasn’t killed me.  Now this.  Who are these people that want to oppose me and why? Why should I bow to them.  I ‘d rather die than do that.  People have sacrificed their lives for me to be in my current position. If this is my time and place to sacrifice myself for the good of humanity, I‘ll do it. The truth will prevail. I opened my computer and within two hours, I had written a response with over 60 references.  One of the lines of my paper said this is not Dementia Pugilistica.  I was agreeing with them.  I discovered I knew the science better than them.  I discovered what they should have discovered, the supposed experts.  I discovered that the NFL, and their so-called MILD traumatic brain injury committee--they coined the term mild because they wanted to diminish the seriousness of concussions-- I discovered that the so-called NFL doctors did not have a good grasp of science (and concussions).  I said, “let us enhance ( our scientific knowledge), and tell the truth, and enhance the sport.  You can never develop solutions to a problem if you don’t even recognize and acknowledge there is a problem.”

Dr. Omalu points out that by the 7th NFL MTBI committee paper, they were making statements that suggest players who have suffered a concussion and who are sent back to the field actually do better.  “This is industrial-scale corruption,” states Omalu.  “These men (football players) are being used as tools.  The majority of them come from just six southern states.  The majority of them come from poor backgrounds.  They lie to them.  They tell them this is your way to go up the economic ladder.  They lie so they have a constant supply.  Sometimes they start playing as young as five years old.  They get repeated blows to the head.  I estimated Mike Webster sustained as many as 200,000 blows to the head in his lifetime.  By the time they get to the NFL, they play an average of 3 years, then they fall out (and disappear) because of the constant supply.  They retire.  They suffer.  They don’t have money.  Nobody is paying attention. What I have is stronger than what they (the NFL) have.  And that is the truth, and one truth is more valuable than their billions of dollars.  That is why they are afraid of the truth.  Let them publish a paper to prove me wrong.  Then I will listen.” 

“Our first duty, like Hippocrates said, is not to science, it is to heal.  We use the science as a tool to heal.  And that is just what I did.  If there is a sport that destroys your mind, should we be playing that sport? Football is selling a product that does harm to mankind.  But what has really hurt the most was having my fellow doctors ridicule and dehumanize me.  Can anybody tell me what I have done so wrong?”  Omalu suggests that American culture has used this opportunity to discredit and dehumanize him because they are unable to accept that someone who is black, and a foreigner from Nigeria to boot, and so young, could have picked up this diagnosis from right under the very noses of the NFL and the medical world.  “Another fellow doctor once said to me that he didn’t think it was race.  It was more about a foreigner coming to America and telling Americans how to live their lives (by not playing football).  I think the NFL has done a phenomenal job to juxtapose football with America’s sense of nationality.  To America’s identity.  Football and apple pie. What could be wrong with these two things?  It’s no longer about science. It’s now a conflict between science and culture.”