Who scored last?

The human brain​ is softer than tofu, squishier than a jellyfish, slightly more robust than toothpaste. Brain surgeons tend not to use scalpels because the substance they work on is too delicate; instead they use ultrasound and suction probes, using breaths of air to suck away diseased bits of matter. A thin layer of cerebrospinal fluid – a hundred millilitres or so – cushions the brain from the skull. The brain’s billions of nerve cells are connected to one another by means of fragile filaments called axons. Axons are the way brain cells communicate – the way thought, memory, balance and movement are maintained – and with every blow to the head they are vulnerable to breakage.

When one object collides with another, the force it exerts is the product of its mass and the rate of change in its velocity as a result of the collision. The heavier and faster the objects, the greater the force on impact. In the late 1980s the average player in the New Zealand rugby union squad weighed around 92 kg. In 1995 rugby union was professionalised, and it became increasingly important that the game was entertaining for TV audiences. The injury rate nearly doubled between 1993 and 1997, and the frequency of tackling also began to climb: in 1987, 94 tackles per match; in 1995, 113; in 2003, 189. This was a new era for rugby, exemplified by spectacular players like New Zealand’s Jonah Lomu, who was 6’5’’ and 119 kg, and could run a hundred metres in 11 seconds. Lomu died in 2015; when I searched his name online, some of the top results were: ‘He was IMPOSSIBLE to stop’; ‘Jonah Lomu Smashing People for 4 Minutes’; ‘Like a Train Smash’. Other national federations took the hint, and players got bigger, faster and stronger. By 2019 South Africa’s national team weighed in at an average of 102 kg, and its forwards – the players in the scrum, who also do most of the tackling – at an average of 118 kg. ‘Rugby is a collision sport and you cannot deny there has been an increase in injuries,’ the former England team doctor Phil Batty says. ‘It used to be that the forwards wouldn’t be quick enough to catch the backs but now, with greater emphasis on fitness training, they are and then you can get serious collisions. That, in very simple terms, is what has happened to club rugby.’

The one-time rugby journalist Sam Peters has written for the Scotsman, the Telegraph, the Independent and the Sunday Times. He also worked for many years at the Mail on Sunday, where he started a campaign to change the game’s rules to give players better protection from concussion. Concussed is the story of that campaign, as well as an account of the transformation of professional men’s rugby from a contact sport played by big men into a collision sport played by giants.

Concussion is widely defined as an injury to the brain that causes a disturbance in brain function, however transient. Most concussions don’t cause loss of consciousness: if you are even slightly dazed or disorientated after the blow, that’s a concussion. Helmets and other protective headgear don’t make much difference to the risk. As the players in professional rugby got bigger and faster, concussion rates began to rise. The incidence in the UK rugby union Premiership quadrupled from 40 in the 2002-3 season to 160 in 2019-20 – a rise that can’t be put down solely to increased recognition and better recording. There’s a growing body of evidence that repeated concussions, even without loss of consciousness, increase the long-term risk not only of dementia, but also of Parkinson’s and motor neurone disease (MND), which killed the former Scottish international Doddie Weir last year. The mechanisms aren’t well understood; there’s a lot we still don’t know about brain injury. An Italian study from 2005 found that among professional footballers the incidence of MND was 6.25 times higher than in the general population, perhaps in part as a consequence of the repeated heading of heavy footballs; a study of American football players found rates of dementia 19 times higher than normal. In 2015 the National Football League in the US reached a $1 billion settlement with 18,000 retired players in compensation for their exposure to concussion-related brain injury.

The risks of concussion in sport have been known for a long time. In the 1890s it was reported that repeated head injuries increased the risk of dementia; in 1928 a pathologist who had conducted autopsies on boxers first described the syndrome now known as ‘chronic traumatic encephalopathy’ (CTE). Eight years later Dr Edward Carroll Jr wrote an article called ‘Punch Drunk’ in the American Journal of the Medical Sciences: ‘No head blow is taken with impunity, and each knock-out causes definite and irreparable damage. If such trauma is repeated for a long enough period, it is inevitable nerve cell insufficiency will develop.’ In 1952 the chief of surgery at Harvard, Augustus Thorndike, wrote that American football players should retire from the sport after sustaining three concussions. Today, a professional boxer who has been knocked out is barred from fighting for between thirty and ninety days, but in rugby, players are often allowed to return after as little as six days.

Chris Nowinski, a former wrestler and now a neuroscientist, is the co-founder of Boston University’s centre for the study of CTE and has mounted a sustained campaign to raise awareness of the dangers of repeated concussions. ‘The only people in the world who reject our findings are medics employed by sports bodies,’ he says. A pathologist who works with Nowinski, Ann McKee, has described the way she was received by sports industry professionals: ‘I met with Fifa in Zurich at a concussion conference. I am very unpopular there. They just have a very low opinion of my work and they told me that it was very poor science. You would think they would be concerned about the players that made them wealthy. Apparently not.’

Not all sports doctors have dismissed the link between repeated concussions and long-term brain damage. The former Ireland international Barry O’Driscoll quit his role as medical adviser to World Rugby in 2012 over the introduction of the Pitchside Suspected Concussion Assessment – he believed it had been introduced not for the benefit of players, but to make it easier for coaches to get them back on the pitch. ‘Rugby is trivialising concussion,’ he said a year later. ‘If a boxer cannot defend himself after ten seconds he has to have a brain scan before he comes back. And we’re not talking ten seconds for a rugby player, we’re talking maybe a minute that these guys are not sure what is going on.’ Rugby players aren’t given a brain scan before they’re allowed back on the pitch, but are asked some basic questions (‘Who scored last in this match?’) and have to do a balance test: ‘walking forward with the heel touching the toe of the foot behind at each step’. They’re usually back playing within a few minutes.

Nowinski likens permitting injured players to return to the field to giving a drunk the keys to his car because he insists he’s safe to drive, and Peters gives several examples of medics who have bowed to coaches’ and managers’ insistence that a concussed player get back to the game. He quotes the Rugby Football League’s first head of medicine, Lisa Hodgson, talking about a pitch-side encounter she had with the renowned player and coach Alex Murphy: ‘“You don’t bring that player off,” and then he looked me straight in the eyes and said, “unless he’s ——ing dead.”’ And then he pushed me onto the field.’ In 2009, it was discovered that at a game between Harlequins and Leinster, the Harlequins’ physio, attending a player on the field, slipped him a fake blood capsule to bite down on, enabling a late substitution. The team doctor, Wendy Chapman, was later suspended by the GMC for cutting the player’s lip after the fact to make the injury seem real. Only since 2019 has it been mandatory in the professional game to have an independent doctor on the touchline.

As Peters sees it, rugby training grounds are ‘like extensions of boys-only private schools where mickey-taking and the slightest sign of weakness could be preyed upon and brutally exposed’. When he began reporting on rugby in the early 2000s, players thought knock-outs were funny; he describes a ‘concussion forum’ at Twickenham in 2013 at which a doctor called Michael Turner played videos of jockeys falling on their heads, to laughs. One strand of the book follows the story of Jeff Astle, a former professional footballer who developed early-onset dementia and whose family have since campaigned for awareness of the link between headers in football and CTE. ‘You can be a jokester and an entertainer,’ his daughter said of Turner, ‘but not when you’re talking about people’s lives.’ Following a match between South Africa and England in June 2009 which became known as the Battle of Pretoria, five England players and one South African were taken to hospital. ‘Rugby is a contact sport,’ the South Africa coach, Peter de Villiers, said. ‘So is dancing … Do we really respect the game? If not, why not go to the nearest ballet shop, buy a tutu and enjoy it?’

‘You  don’t want to take anything away from rugby’s sheer gladiatorial nature,’ Damian Hopley, a former England international and chief executive of the Rugby Players’ Association until last year, told Peters in 2014. ‘But you often watch a game and think, “How on earth do these guys get up after that hit?”’ This is another way of posing the question at the heart of Peters’s book. Is rugby a participation sport, or an entertainment spectacle? Which should take priority? The newer style of play is making a lot of money for a lot of people, but there is unequivocal evidence that injury rates are climbing, and that repeated head injuries can and do cause permanent damage to the brain.

Gladiators were often expendable slaves, sometimes prisoners of war, who if successful could make money for their owners and sometimes win their own freedom. Peters notes that top rugby players can make more than £250,000 a year, but many professionals earn closer to £20,000. How much does a player need to earn to make it worth the risk of permanent damage? The median salary for an American football player in the NFL is around $860,000; the top players make more than $30 million per year. Is that enough? Billy Vunipola, whose father came from Tonga to play in Wales and who has 71 caps for England, was asked in an interview by the former Scotland international Jim Hamilton whether he ever thought about the prospects for his life and health beyond the age of fifty. ‘This is the life I chose, this is what I signed up for,’ Vunipola said. ‘I would love to be like the healthiest person in the world, but that’s just the way it is and you’ve got to accept it.’ Hamilton agreed: ‘I grew up on a fucking council estate … I had nothing, right? Rugby gave me everything … all I know is I had the best fucking fifteen years of my life.’ Peters quotes the former New Zealand All Black Carl Hayman, talking about his early-onset dementia: ‘I was a commodity, and I understood that … It’s like that scene in [Band of Brothers] when the guy tells the bloke with shell shock: “When you accept you’re dead, you can function as a soldier.”’ Shontayne Hape, a New Zealander who played for England but was obliged to retire in 2013 because of repeated head injuries, has described being under ‘constant pressure from the coaches. Most coaches don’t care what happens later on in your life. It’s about the here and now. Everyone wants success. They just think, “If we pay you this you are going to do this.” Players are just pieces of meat. When the meat gets too old and past its use-by date, the club just buys some more.’ Professional Rugby Union in England has an estimated annual turnover of £280 million. Of this, Peters writes, just £800,000 is set aside for player insurance against injury; £2 million, meanwhile, is set aside for dinners and social events organised by the Rugby Football Union council.

Women’s rugby has the same problems with concussion as the men’s game. Peters highlights the case of Siobhan Cattigan, a Scottish international who in 2021 killed herself after suffering chronic pain and mood problems that her parents say began with head injuries she sustained playing rugby. And where the professional sport leads, entry-level rugby follows. The worry is that the transformation of the game as it is played at Twickenham and Murrayfield has put players of school and amateur rugby in greater danger. Peter Robinson’s 14-year-old son Benjamin died in 2011, his life-support machine switched off two days after he sustained three head injuries in a single game – a game during which his mother was told by the referee to ‘calm down’ when she questioned whether he should be allowed to play on. Robinson has led a campaign with the slogan ‘If in doubt, sit them out,’ which has made some progress in protecting children from injuries of the sort his son sustained. ‘No one should die playing a game,’ Robinson tells Peters. ‘It is not war, whatever some people would have you believe. If there is any suspicion a player has suffered a brain injury, they should leave the field immediately.’

In 2016, seventy health professionals wrote an open letter to the UK’s chief medical officers asking for a ban on tackling in rugby in schools. One of the signatories was Allyson Pollock, a professor of public health. ‘World Rugby determines the laws of the game,’ she wrote in 2015, ‘but its interests are in the professional game and business around it. Children have no representation in the national rugby unions and their welfare and interests are not paramount.’ Another of the signatories, Eric Anderson, argues that ‘schoolchildren should not be forced to collide with other children as part of the national curriculum for physical education.’ There are those who will respond that kids have to learn sometime – after all, at eighteen they’ll start having to play by adult rules.

In December 2018, a French rugby player called Nicolas Chauvin died at the age of eighteen from brain damage and cardiac arrest after a two-man high tackle fractured his second cervical vertebra. Rugby, his father said, has given way to ‘the show’. That same year, also in France, Louis Fajfrowski died at 21 from a legal chest-high tackle – he had a cardiac arrest back in the changing room. Peters quotes a French doctor: ‘The injuries we see today are more like road traffic accidents. The man who plays rugby today is heavier and runs faster. The shocks are stronger. It is a very big inflated engine on a chassis that was not designed to support it.’ I was struck by that comparison: in my own work as a GP I’ve often wondered how much the rise of anabolic steroid use among teenage boys is part of an attempt to match up to these enormous, lionised players.

Peters has left rugby journalism, having made, he implies, too many enemies. He has, he writes, ‘found it increasingly difficult to love a sport whose administrators have lost their capacity for compassion … if we are going to cheer on the collisions, we have to admit they come at a price.’ He ends his book by outlining a few sensible solutions: change the rules on tackling; reduce the intensity of players’ schedules; lower the injury threshold for the removal of players from the field, and increase the interval before they’re allowed to return; tweak the rules on substitutions; stiffen the punishments for clubs that break the rules. But progress is slow; Peters has the figures to show that despite widespread awareness of the problem, concussions are not diminishing.

Two thousand years ago Galen, physician to the gladiators, wrote that he wouldn’t recommend being an elite athlete because of the number and severity of the injuries it exposes you to and the bizarrely unbalanced lifestyle such a career demands. When professional rugby players reach their late twenties or early thirties, too slow or too injured to go on playing at a high level, they retire to find other careers, hoping all the while that they won’t develop CTE, or another neurodegenerative condition. Maybe that’s progress of a sort: when Galen’s gladiators slowed down in the arena, they got killed.