I’ve been thinking a lot about risk lately. In medicine and public health, it’s an idea that’s always present, usually invoked toward the goal of disease prevention. Over the years, the ways in which the concept of risk has been put forth have changed as the major causes of mortality have shifted from infectious to chronic disease. In the eighteenth and nineteenth centuries, an epidemic of cholera or yellow fever might have been seen as a way to separate acceptable citizens from unacceptable, the latter premised on some combination of ethnicity, race, religion, class and moral principles. More recently, public health recommendations have focused on lifestyle practices that can reduce our risk of developing cancer, heart disease, and other chronic illnesses with multifactorial causes.
I’m interested in how we experience risk and how this shapes the decisions we make about what to eat, where to live, the types of behaviors we engage in and the situations we’re comfortable with. How does each of us choose to respond to a series of unknowns about, for instance, the dangers of genetically modified food, the possible link between cellphone radiation and cancer, or the relationship between pesticides and hormonal imbalances? If Alzheimer’s disease runs in your family, what do you do to decrease the chances you’ll develop it? If you’re diagnosed with a precancerous condition that may or may not become invasive, do you remove the suspicious cells immediately or wait to see if they spread? What does it mean for our bodies to be constantly at risk, under threat from sources both known and unknown that we cannot see or regulate?
In the upcoming months, I’ll be exploring these ideas and more in a series of essays on risk. My premise is that the ways in which we choose to deal with risk are fundamentally about control, and are aimed at addressing the illusion that we have command over disease outcomes in a world ruled by randomness and unpredictability. Cancer screenings, lifestyle habits, and the other behaviors we adopt to stay healthy are an attempt to reduce our risk, to make the uncertain certain, to bring what’s unknown into the realm of the foreseeable. As a way of managing the future, this approach assumes a linearity of outcomes; if I engage in x behavior, then I will prevent y disease. It assumes that illness can be reduced to a series of inputs and corresponding outputs, that wellness is more than a game of chance or a spin of a roulette wheel. The boundaries of what we consider reasonable measures to embrace for the sake of our health will differ for each of us based on our individual tolerance for ambiguity and what we consider an acceptable level of risk. As I delve into an investigation of the relationship between risk and health, the underlying question I’ll be concerned is this: what level of uncertainty can each of us live with, and how does it affect our behavior?
So here goes, my first essay in an ongoing series on risk.
With the Denver Broncos’ 24-10 victory over the Carolina Panthers in Super Bowl 50, the 2015 football season came to its much-hyped conclusion. I didn’t watch the game, but I have been following closely any public health news involving the National Football League. Just days before the Super Bowl, the family of Ken Stabler, a former NFL quarterback, announced that he suffered from chronic traumatic encephalopathy (CTE), a degenerative brain disease that can trigger memory loss, erratic behavior, aggression, depression, and poor impulse control. The most prominent quarterback yet to be diagnosed, Stabler joins Junior Seau, Frank Gifford, Mike Webster, and over 100 former players found to have the disease, which is caused by repeated brain trauma and can only be determined after death by a physical examination of the brain. Retired NFL players suffer from numerous chronic injuries that affect their physical and mental well-being: in addition to the multiple concussions, there are torn ligaments, dislocated joints, and repeated broken bones that can no longer effectively be managed by cortisone injections and off-the-field treatments. Many athletes end up addicted to painkillers; some, like Seau, commit suicide or die from drug overdoses, isolated from family and friends. One particularly moving article in the New York Times profiled Willie Wood, a 79-year old former safety for the Green Bay Packers who was part of the most memorable play of Super Bowl I, yet can no longer recall that he was in the NFL. And incidents of domestic abuse against the partners and spouses of players continue to make headlines, including the unforgettable video of Ray Rice knocking his girlfriend unconscious in an elevator at an Atlantic City casino.
Despite these controversies, football remains enormously popular in the United States. Revenue for the NFL was $11 billion in 2014, and league commissioner Roger Goodell pocketed $34 million in compensation that year. The NFL has managed to spin the concussion issue in a way that paints the league as highly concerned about player safety. Goodell touts the 39 safety-related rules he has implemented during his tenure, and the settlement last fall in a class-action lawsuit brought by former players set up a compensation fund to cover certain medical expenses for retired athletes (although some criticized the deal because it doesn’t address symptoms of CTE in those who are still alive). Increasing awareness of the danger of concussions has prompted discussions about how to make the game safer for young athletes. One approach that’s been floated is to have players scrimmage and run drills without helmets and protective padding, forcing them to treat each other gently in practice while saving the vigorous tackles for game day. The Ivy League just agreed to eliminate full-contact hitting from all practices during the regular season, a policy that Dartmouth College adopted in 2010. And earlier this week, the NFL’s top health and safety official finally acknowledged the link between football and CTE after years of equivocating on the subject.
But controlled violence is such a central aspect of football that I wonder how much the sport and its culture can be altered without changing its underlying appeal. Would football be a profoundly different thing with the adoption of protocols that reduce the likelihood of concussions and other injuries? How much room is there for change within the game that football has become? Players continue to get bigger and stronger, putting up impressive stats at younger and younger ages. My friend’s nephew, a standout high school player in Texas and a Division I college prospect, was 6’2” and weighed 220 pounds when he reported as a freshman for pre-season training—numbers that I imagine will only expand as he continues to train, and ones that players around him will have to match in order to remain competitive.
With mounting knowledge of the link between football and degenerative brain disease, I’m interested in the level of risk that’s acceptable in a sport where serious acute and chronic injuries are increasingly the norm. In a recent CNN town hall, Florida senator Marco Rubio asserted that football teaches kids important life lessons about teamwork and fair play, and pointed out that there are risks inherent in plenty of activities we engage in, such as driving a car. True enough, but driving a car is an essential part of daily life for many of us, which means that we have little choice but to assume the associated risks. Football is voluntary. I realize that for some, football is less than completely voluntary, from children who face parental pressure to professional athletes who feel compelled to remain in the game because they’re supporting families or facing limited options outside the sport. Still, playing football is an acquired risk to a greater degree than driving or riding in a car, the dominant form of transportation in our suburbanized communities. And if risk reduction is about attempting to control for uncertainty, then the accumulating evidence about CTE and other severe injuries is sure to change the calculus of how parents and players assess participation in a sport where lifelong mental and physical disabilities are not just possible, but probable.