Contact sports cause CTE. So why are Americans watching more football than ever?

In January 2023, minutes after Damar Hamlin collapsed on the field following a tackle, my cellphone was humming with a steady stream of messages from friends, family, and acquaintances who had been watching the game. How could this happen, they wanted to know. Could a single, seemingly routine collision between two very-large men really cause one of their hearts to abruptly stop beating?

It could, and it had, I found myself explaining to the non-physicians in my social orbit over the next few days as Hamlin remained on ventilator support in the ICU. At the time, Hamlin was 24 years old and appeared to be in peak physical health. To have seen the life, quite literally, clobbered out of him was highly distressing, to say the least, and those who witnessed the sudden collapse — even if from the comfort of their own recliners — were, understandably, shaken. I had many football-focused conversations that week, and a significant number of them ended with my interlocutor somberly vowing to take the dangers of the game more seriously.

But as a neurologist who regularly treats patients with neurodegenerative illnesses, I met these pronouncements with some skepticism, a modicum of hope, and an enormous amount of frustration. While suffering from a cardiac arrest near the 45-yard line is a terrible event, it is also exceedingly rare. The risk of developing chronic traumatic encephalopathy from repeated blows to the head sustained over the course of a career in football, however, is not.

Over the past decade, research linking repetitive head injuries to the development of memory impairment, overall cognitive decline and mood, or behavioral issues has grown significantly. Just within the past six months, we’ve seen particularly unsettling reports of CTE ending the lives of athletes barely old enough to vote. Yet, in the 20-plus years since neuropathological evidence of this disease was first found in the brains of NFL players, I have scarcely heard anyone suggest that, as a result, they plan to reconsider their fandom.

One of the reasons for this is obvious. While Hamlin’s collision and fall took place in quick succession on live TV, the symptoms of CTE may not emerge until years after the head injuries happen. This delay in onset is not unusual for neurodegenerative illnesses — the initial physiological insults that eventually produce the well-known symptoms of Alzheimer’s or Parkinson’s disease may take place decades before any deficits are outwardly apparent. This chronological gap between event and consequence has undoubtedly made the public less likely to shoulder any misgivings about tuning in to Monday Night Football. And, while it’s true that a smattering of articles considering the ethics of watching football have emerged as research linking CTE to contact sports has continued to accumulate,  both college and professional football viewership are on the rise.

Another reason for Americans’ seeming indifference to the neurological fates of the athletes whose jerseys they proudly don is, I would venture, good old cognitive dissonance. The brain regions most commonly implicated in the mental phenomenon responsible for making us a bit queasy when trying to hold two competing beliefs at once are the left anterior insula and multiple areas of the frontal lobe, which deal in the realms of unpleasant emotion and executive function, respectively. Cognitive neuroscience research has shown, repeatedly, that when we choose between two ideas or actions that are at odds with each other (i.e., “I wish to mitigate suffering secondary to neurological illness” and “Go Steelers!”), we actually change our preferences simply by making the choice, a process which we then feel compelled to justify. Thus, if we decide to keep watching football, our brains conclude, perhaps the research on contact-sports and CTE is inconclusive?

Unfortunately, this isn’t the case.

But if we are, collectively, unconcerned by what may befall the brains of professional athletes over time, the same does not appear to be true for the brains of our own children. In a 2017 survey conducted at the annual conference of the Texas Neurological Society, 68.4% of the respondents (all of whom were neurologists) indicated that they would not support a young male relative playing football. More broadly, a recent investigation by the Washington Post found that participation in high school football has declined, overall, by 17% since 2006. (Polling also identified significant differences in sports enrollment along political, cultural and state lines.)

These statistics raise an obvious question: If football isn’t safe enough for our own kids, is it safe enough for anybody’s?

In a word, no. Or, at least, not yet. In the 20 years since CTE became a household acronym, rule changes ostensibly aimed at minimizing the risk of bodily injuries, including blows to the head and concussions, have been implemented, but their efficacy remains questionable at best. Even so, CTE activists and scientists have not lost hope. In response to a letter signed by 41 of the world’s most prominent CTE researchers in 2022, the National Institute of Neurological Disorders and Stroke publicly acknowledged the causal link between chronic traumatic encephalopathy and “repeated traumatic brain injuries” for the first time. Even Ann McKee, director of the CTE Center at Boston University, who has either lead or contributed to a large portion of the existing scientific literature tying CTE to contact-sports, believes that the game of football could be changed in ways that would minimize its contributions to neurodegenerative disease. In the meantime, the research community is moving full steam ahead toward developing methods for early detection and treatment.

One of the many remaining mysteries of CTE is why some individuals who suffer repeated head strikes go on to develop the disease while others don’t. A recent publication in the journal JAMA Neurology has suggested that a genetic variant known as ApoE4, which is already known to confer an increased risk of Alzheimer’s disease, may also make those who experience head trauma more likely to develop CTE. However, confirmatory studies would need to be carried out before anyone might recommend that football players consider undergoing pre-season genetic testing.

In the meantime, like any significant public health crisis, what CTE needs in an effective spokesperson. Perhaps one with tens of millions of fans who is adored near-universally and, to boot, has a legitimate, personal stake in both the health of the player(s) and the endurance of the game?

Taylor, if you’re reading this, let’s talk.

Adina Wise is a neurologist and writer in New York City.