Ronald Hamilton, M.D., UNMC College of Medicine, class of 1989, describes what happened this way:
“My student handed me a small pebble, and said, ‘Is this what I think it is?’ And I said, ‘Yes.’ And I threw the pebble to the ground.
“And it started an avalanche.”
It did. The “pebble” turned out to be a groundbreaking discovery on traumatic brain injury. This new finding changed the way we look at one of our national pastimes, football. It led to controversy, a national conversation, and eventually, a movie, “Concussion,” starring two-time Oscar nominee Will Smith.
The movie also has a “Ron Hamilton” character. The Omaha native (Omaha North, University of Nebraska-Lincoln, UNMC) is part of this story, too.
Dr. Hamilton’s mentee, Bennet Omalu, M.B.B.S., had gone to extraordinary measures to make a discovery that changed everything. But Dr. Hamilton was the senior scientist who confirmed the discovery and staked his reputation to it.
When the National Football League, through its Mild Traumatic Brain Injury committee, demanded a retraction – a rarity in science – “my career was on the line,” Dr. Hamilton said.
But the science, and further cases, vindicated Drs. Omalu and Hamilton. Their careers haven’t been the same since.
It began in 2002, when Mike Webster, a Pro Football Hall of Fame player, died at age 50 after suffering from what he himself had previously called football-related dementia. Webster’s body came to the Allegheny (Pennsylvania) County Coroner’s Office, where Dr. Omalu worked.
Already a forensic pathologist, Dr. Omalu had invested several years of further training with Dr. Hamilton to eventually also become a neuropathologist. He wanted to distinguish himself within the field. “Really, a go-getter guy,” Dr. Hamilton said.
Dr. Omalu, an immigrant from Nigeria, did not know who Webster was. “He didn’t know football from baseball,” Dr. Hamilton said. But if the man on the table before of him had suffered from dementia, Dr. Omalu felt he owed it to Webster to look at his brain.
This was unusual. Most times, cause of death would be considered “natural,” and that would be it. Dr. Omalu got the OK to investigate further, but was told he needed to work on Webster’s brain on his own time, on his own dime. He did, in part working with Dr. Hamilton’s lab at the University of Pittsburgh School of Medicine, where Dr. Hamilton is director of the neuropathology core and an associate professor of pathology.
Dr. Hamilton said there are certain cases neuropathologists see all the time. And then there are those you see only in textbooks, or once in a lifetime. In Webster, Dr. Omalu had found the latter.
Dr. Omalu stopped by Dr. Hamilton’s office to confer with his mentor. Dr. Hamilton recalls being given the slides “blind,” with no other information. Just tell me what you see.
Dr. Hamilton is known worldwide, within the field, for having made strides in the study of Alzheimer’s disease. He’s an expert. Looking at the slides, he ticked off what this case wasn’t. At last, he came to a conclusion.
Dementia pugilistica. A boxer.
No, Dr. Omalu said. This was a football player. This was Mike Webster.
Oh, of course. Then and now, it made perfect sense. “It didn’t even phase me,” Dr. Hamilton said.
It would be interesting to see how many times former football players had been diagnosed with this condition, Dr. Hamilton said.
But Dr. Omalu had already checked the literature. The answer was zero. This was a new discovery. Mike Webster was the first.
“That’s when my jaw dropped,” Dr. Hamilton said. “I knew right at this point, this was not going to be the last case. There were going to be lots of other cases.
“No neuropathologist had ever looked at the brain of a football player before.”
Dementia pugilistica no longer sufficed. This was new. In consultation with Dr. Hamilton, Dr. Omalu coined the term chronic traumatic encephalopathy. Scientists love a good acronym. It would be called CTE.
(To be technical, dementia pugilistica is a form of CTE.)
Today, CTE is all but a household word among football fans.
But as they wrote up this first case study for publication, Dr. Omalu and his collaborators knew to tread carefully.
“When you submit a paper to a journal, the standard practice is they will send it to two reviewers who will review it,” Dr. Omalu said, in an interview with PBS Frontline. “If the two reviewers agree this is a good paper, it’s published. They’ll make some comments, make some changes. Assuming the two reviewers disagree, it’s sent to a third reviewer . . . so if it’s two-to-one, OK. Do you know the number of people that reviewed this paper? There were over 18.”
“It was an incredible peer review process,” Dr. Hamilton said. “That just made it stronger. When the paper got published we were very happy about it.”
Not everyone was. The book “League of Denial” put it this way: “the NFL’s doctors took out their scalpels and the long knives.”
A handful of physicians, who coincidentally served as the National Football League’s Mild Traumatic Brain Injury committee, wrote the journal demanding a retraction.
“That’s like a nuclear option,” Dr. Hamilton said. “When you demand a retraction you are saying it’s faked, it’s false, incorrect to such a degree ….
“We were just stunned.”
In the movie, clip below, “Ron Hamilton” tells his friend Bennet that they could just retract their findings and make the controversy go away.
“I cringed,” watching that scene, the real Dr. Hamilton said.
In real life, “I was furious. I was really upset. Bennet was even more upset.”
But Dr. Omalu later said that as he read the rebuttal, he realized something. These doctors, none of whom worked with the brain, were not on solid ground scientifically.
And then something else happened. Another former Pittsburgh Steeler died tragically, too young. His body also came to the Allegheny County Coroner’s Office. A colleague saved the brain for Dr. Omalu.
Terry Long also was found to have suffered from CTE.
Then, another former pro football player killed himself. When Dr. Omalu examined his brain, CTE. Another, killed in a car crash after an incident with police. CTE.
And another. And another. CTE.
“When we got that first case, we didn’t really understand what the magnitude was going to be,” Dr. Hamilton said. “I myself thought that maybe 1 in 100 or 1 in 500 might get it. … I didn’t think it was going to be as pervasive.”
In part because no one had ever before thought to look for it. “It’s kind of like the California gold rush,” Dr. Hamilton said. “Why had no one discovered gold before? It was right there. If you weren’t looking for it, you won’t see it. But if you know to look for it, you’ll see it everywhere.”
More cases rolled in. While some continued to doubt, other scientists eventually signed on, confirming and accepting CTE; some formed their own, quasi-competing research groups. All the while, Big Football continued to throw its weight into pushback of Dr. Omalu’s findings (it was only earlier in 2016, after about a decade of denials, that anyone from the NFL would acknowledge a link between its sport and CTE).
Dr. Omalu, who hadn’t known the hornet’s nest he would stir up, who began all this as what he called “a nobody,” started to feel stress on multiple fronts. Yes, he was suddenly a famous scientist, but …
“It was a double-edged sword,” he told PBS, “because I began to be exposed to (these players’) lives. It started becoming personal to me. I started meeting the family members.”
“He’s not just some distant pathologist looking at slides,” Dr. Hamilton said. “He’s involved with people.”
The emotion, the human drama, the politics, the public scrutiny could be overwhelming at times. There were days, he told friends, he wished all of this had never happened. He wished he had never met Mike Webster.
“I said, ‘Bennet, you don’t know how many people you are saving because of this,’” Dr. Hamilton said.
Dr. Omalu famously wrote an A-section essay for The New York Times entitled “Don’t let kids play football.” You may have heard that Dr. Omalu’s mentor publicly disagreed, instead countering in a media conference call, “I’m a big believer in the benefits of organized sports and the benefits of football.”
Dr. Hamilton was not that mentor (the mentor in question is Dr. Julian Bailes, chairman of neurosurgery at the NorthShore Neurological Institute. Dr. Bailes’ sons played football. He formerly served as team physician for an NFL team and he is medical director for the nation’s largest youth football organization).
No, “Neuropathologists know hitting your head is bad,” Dr. Hamilton said.
The brain, he explained, floats in fluid inside of your skull. How does brain injury happen? “It’s not just the head-to-head hits,” Dr. Hamilton said. “It’s any time the brain is moving and stops suddenly.”
And that’s what happens when humans slam into one another, when they fall hard to the ground, when their necks snap quickly. In other words, what happens when they take part in contact sports.
The very title of the movie – “Concussion” – doesn’t tell the full story, Dr. Hamilton said.
Subconcussive hits, routine hits fans might not even notice, ones that happen multiple times every day in practice, also can contribute to CTE.
“No helmet in the world can stop the brain from moving around inside the skull,” Dr. Hamilton said.
Does that mean he believes football should be abolished? No. But make it an age-appropriate activity, Dr. Hamilton argues. Take all contact – all use of helmets – out of practices, so that the risk is limited to just several plays a week, several weeks a year, and only for the starters, who actually play in the games.
This is how you save America’s favorite sport.
The movie. “We knew it was Hollywood,” Dr. Hamilton said. “And we knew Hollywood was Hollywood.” Meaning, it wouldn’t be a scientific paper, they realized that. It was a story, one that needed heroes and villains.
“The movie ended up taking lots of very complex things and smashing them into one scene with three people,” Dr. Hamilton said.
“Ron Hamilton” didn’t dress the way the real Ron Hamilton would dress. (White coat and suits and ties? Only on special occasions.) And “Ron Hamilton” didn’t always necessarily say what the real Ron Hamilton had said.
The moviemakers asked the real Dr. Hamilton for props, but not for technical advice.
But it was great fun.
“For me and Bennet both, all those were just details,” Dr. Hamilton said. “The impact of the movie, when you watched it, it was, ‘Oh my gosh.’”
If you want to know the real story, all the nitty-gritty details, Dr. Hamilton recommends the book “League of Denial.”
But only a movie, only a star like Will Smith, could have the public impact “Concussion” had.
“We thought the most important thing the movie could do was increase the conversation,” Dr. Hamilton said, “and it did that.”
Now, almost everyone acknowledges CTE. Even those emotionally invested in football. Even the NFL.
And the study continues. “We know a little tiny bit about a little tiny bit,” Dr. Hamilton said.
More and more former football players have been diagnosed, via autopsy. So have victims of chronic domestic violence. Military personnel killed in combat.
Like so many of us, Dr. Hamilton said he now scans the sports pages, sees athletes who are troubled, and wonders how many of them are suffering from CTE.
But like Alzheimer’s, CTE can’t be diagnosed definitively until a person dies and scientists look at his or her brain.
“We’re at the very beginning of this,” Dr. Hamilton said. “It’s only been 10 years.”
He continued: “It’s up to the physicians and scientists who work in living people to carry this on. We identified the disease in the dead.”
It happened because a young investigator was invested in his work and took a chance. He took the result for a second look by his mentor and friend.
It started an avalanche.