While concerns about brain injuries in sport are not new, the current “concussion crisis” is unique in that it is a broader cultural crisis. (photo via Popular Science)

There is a concussion crisis in sport. In some ways, concern about brain injuries in sport is nothing new. Over a century ago, medical journals started campaigning against the dangers of sport, and there were specific attempts to ban U.S. college football in the early 1900s and abolish tackle football in the 1950s. But the current crisis is different in four key respects:

  1. It is a multisport injury crisis, spanning combat sports, various forms of football, hockey, and lacrosse to name but a few.
  2. The crisis is global in nature, with debates in North America paralleled in most other English-speaking nations and, increasingly, mainland Europe.
  3. The crisis extends beyond one type of injury—concussion or traumatic brain injury (TBI)—and is now inseparable from concerns about second impact syndrome and chronic traumatic encephalopathy (CTE). It even includes concerns about the influence of barely perceivable “sub-concussive” impacts.
  4. The crisis is distinct in terms of its penetration into the popular cultural imagination, notably through the book and documentary League of Denial and popular movie Concussion.

Until now the issue of concussions has been approached in relatively narrow terms: as a medical problem; a media phenomenon; a governance and regulation issue; and a public health failure. It is, of course, all of these things. Within these areas, more work is needed to effectively diagnose, identify which particular impacts and/or symptoms equate with short- and long-term harm and, most fundamentally, find some kind of medical “cure”. We also need to examine media portrayals, scrutinize administrators’ responses, and change the way concussion awareness campaigns are designed and delivered. But many sport stakeholders and athletes have been slow to react, and the crisis has become bigger than any of these things alone—it is now a cultural crisis.

Conceived of as a cultural crisis, we now need to ask new and different questions, for health crises are rarely simply the outcome of the most pressing concerns, but are socially constructed through ideologies, interests and power relations. In light of this it seems pertinent to ask, what kind of society is it in which concerns over brain injury in sport have become so pronounced? What are the social roots of sport’s concussion crisis?

These are the fundamental questions I attempt to address in a new book, The Concussion Crisis in Sport. The analysis identifies three changing but interconnected cultural ideologies that help us understand the current situation: 1) health; 2) ageing; and 3) of course, sport.

First, concerns about concussions grow out of changes in the way we conceive of health in contemporary societies. Where health was once simply the absence of illness, we now think of health more in terms of our ability to optimize wellbeing through self-management. Concussion is a distinct contemporary health issue because our concerns are not just about the here and now, but also longer term risks, such as dementia and other forms of cognitive impairment.

Moreover, because healthiness has become entwined with ideas about our ability to be in control, brain health has taken centre stage. Neuroscience may be at a relatively early stage of development, but our expectations about how a deeper understanding of the human brain will enhance the human condition are reflected in the burgeoning market for brain enhancement products sold to consumers looking to develop their cognitive capacities. The exponential growth in social awareness of mental health issues is another expression of this. Specifically, while Mike Webster’s NYT obituary explicitly identified sport-induced brain injury as the cause of his 2002 death, it was the broader context (George W. Bush had just launched a comprehensive mental health review) that fuelled both Bennet Omalu’s investigation of CTE as a distinct medical condition and subsequent public and political interest. The concussion crisis stems from what has been termed Brain Culture and a belief that the brain is the key to understanding human existence and controlling human happiness.

Second, the concussion crisis in sport is also fundamentally wrapped up with concerns about different phases of the life-course. Children, once simply seen as small adults, are now thought of as uniquely vulnerable and in need of “concerted cultivation”. Parents invest in private tuition, after school clubs, etc. with the expectation that these actions will reap rewards for their children’s development. Moreover, because we think of childhood as the “cradle of the self” – the beginning of what defines us – the positive or negative experiences of young people are thought to have a spiralling effect. The result: we encourage children into sports, yet become acutely concerned about the potential effects upon them, such as concussions. These considerations explain how an occupationally specific concern related to the NFL has escalated to encompass all sports participants.

The hopes and fears about children’s early years are compounded by broader demographic shifts. As aging populations and medical efficacy for treating – e.g. heart disease – advance, so dementia has grown as a social concern. The primary response to this has been one of panic and fear – panic at the potential economic and social burden of an aging populace and fear at the prospect that we as individuals might also be subject to this “living death”. Medicine’s inability to develop a cure for dementia has led to a search for “faddy avoidance tactics”. Broader concerns about aging and dementia have spawned an ongoing search for a link between concussions and (early onset) dementia.

Third, changes to the structure and consumption of sport are also at the root of the current concussion crisis. Sport has become increasingly specialised in recent years and money and prestige have helped refine the performance experiments of sports science, creating a breed of “super-human” athletes. While we may not recognise it, the lived experiences of athletes have never been more distinct from that of sports fans due to the degree of devotion and singlemindedness required to become an elite performer.

Helping to obscure these differences is the cult of the sport celebrity. Richard Schickel, in his review of celebrity in modern life, describes how the public are drawn into the lives of these Intimate Strangers, which increasingly includes our consumption of the post-career lives of former sports stars. Inevitably this includes the longer-term detrimental health effects of a sporting career that, until recently, were largely beyond the public gaze. The concussion crisis is fuelled by an industry of sporting nostalgia (consider the focus on dementia amongst England’s 1966 World Cup winning soccer team), and a (misleading) conflation of demonstrably dangerous occupations with routine, everyday forms of sports participation.

So what can be done? Cultural crises are not resolved through technical or scientific innovation alone. Neither helmet design, rule changes, nor reliable diagnostic tools will get to the heart of these issues. We need something more than greater awareness and better regulation, for while both would be welcome, they continually fail because they misconceive the problem at hand.

The solution to a cultural crisis rests on uniting opposing factions and addressing their attitudinal differences. The first step toward doing that is to recognise how the current debate is guided by broader social processes. Our expectations for health, medicine, childhood and aging shape attitudes towards concussions. Second, we need to more clearly distinguish between the very different realities of elite and everyday levels of sporting experiences. This may go against the interests of commercial sport organisations for which forming a bond between player and fan creates meaning which creates revenue, but current portrayals misrepresent the levels of risk that most individuals experience in sport. Moreover, research shows that where regulations are out of step with participants’ experiences of concussion, they are likely to be rejected and ignored. Third, we must address the core paradox fuelling the concussion crisis; namely that what is believed to be a simple, cheap, accessible (and effective) strategy for boosting physical, mental and social well-being has become seen as a central cause of potentially the defining health issue of the twenty first century.

Finally—and many will find this counterintuitive—the way concussion has been elevated above and fundamentally distinct from other sport injury concerns may have had negative consequences. The voices calling for greater protection of the brain are contradicted by those that champion the traditional virtues of strength, fortitude and resilience in sport. A culture of sport that celebrates pain and injury creates an environment where disregard for one’s body is positively encouraged. Locating concussion within a more holistic concern about attitudes and responses toward sport injury, and a more realistic evaluation of the relative health benefits and costs of sports participation, would form the basis of a more authentically cultural agenda for change.

Dominic Malcolm is Reader in the Sociology of Sport at Loughborough University, UK. He is also Editor-in-Chief of the International Review for the Sociology of Sport. He has published a dozen books and over 50 journal articles on a range of subjects within the sociology of sport. His latest book is The Concussion Crisis in Sport (Routledge, 2020).