Factually! with Adam Conover - The Truth about Brain Injuries and Football with Dr. Ann McKee

Episode Date: January 1, 2020

Neuropathologist and Director of Boston University's CTE Center, Dr. Ann McKee, joins Adam to discuss CTE or chronic traumatic encephalopathy, a neurodegenerative disease caused by repeated head injuries that affects the NFL and other sports. Dr. McKee explains just how common and devastating CTE is, why we can't yet identify CTE in living patients, and the origins of her "Brain Bank." Learn more about your ad choices. Visit megaphone.fm/adchoices See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

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So if all of that sounds good, if you want a big box of delicious snacks like this for yourself, use the code factually for $15 off your first order at Bokksu.com. That's code factually for $15 off your first order on Bokksu.com. I don't know the way. I don't know what to think. I don't know what to say. Yeah, but that's okay. Yeah, that's okay. I'm your host, Adam Conover. And look, we know that playing football is not great for your health, right? But most of us don't realize what the real health danger really is. See, if like most Americans, you believe that concussions are the big problem in the NFL, well, then it might appear like the league is doing a good job of taking that problem seriously. This year, the NFL self-reported that concussions went down by 23% in the 2018 season. And part of the reason for that is that they've tweaked the game in order to reduce that specific injury. They've given players better helmets, and, you know, instead of banging their heads together at 300 miles per hour,

players are now encouraged to ram the rest of their massive meat together instead. Aha! Improvement, right? Well, unfortunately, those measures completely miss the real problem. Because the real problem isn't concussions at all. The truth is that we could completely eliminate concussions from football, and the players would still come away with brain injuries bad enough to destroy their lives. See, we now know that it's not just the big bell ringers that cause lasting damage to the brain. The small hits do as well. We're talking wrestling at the line

of scrimmage, diving to catch a pass, and every single tackle, every single one of those adds up. See, we assume that the skull protects the brain, right? That's how we normally think of it. But the truth is that the skull can actually damage the brain as well. Imagine that your brain's a passenger sitting in a car without a seatbelt. Well, when the body is in motion and the head stops too suddenly, well, the brain sloshes forward and collides with the inside of the skull, banging into the dashboard and getting brain goo on the windshield. And when that happens,

even on the small non-concussive hits, the type that happened to football players countless times during their careers, well, they add up over time. And when they do, they can trigger the degenerative brain disease known as chronic traumatic encephalopathy, or CTE. This disease, which can start showing symptoms years or even decades after a player played their last game, is brutal. Its symptoms include memory loss, confusion, impaired judgment, aggression, depression, suicidal thinking, and dementia. And a study of the brains of 111 deceased NFL players found that 110 of them had CTE. And as of now, there is no cure. So even if the NFL were able to completely eliminate concussions from the game, what we're left with is a sport where we're asking young men

to permanently injure and yes, even prematurely kill themselves so that the NFL can make $13 billion a year and so that the rest of us can zone out on Sundays and watch ads for SUVs and beer. And you know what? I personally don't think that trade-off is especially worth it. I'm pretty sure we can figure out a way to sell Chevys that allows 19-year-olds to keep all their higher cognitive functions, you know, but the NFL doesn't seem especially concerned about that, and that means that the sport now exists in a state of moral crisis beyond anything that the league currently acknowledges. Now, I do want to address one argument right off the bat. Some might be tempted to argue that NFL players get paid huge amounts of money, and so taking on the risk of CTE is a choice that they are making rationally. Now, I would argue that that is a bullshit attempt to

deflect responsibility, because when someone has dedicated their whole life to developing a single skill with the encouragement of their parents, coaches, and school systems, and that's literally the only thing that they've ever done, then playing football is not a choice. It's their only option. And in the culture of football, players are deliberately trained to do whatever their coach tells them to. The coach says jump. The player says how high. The coach says take thousands of subconcussive hits that might result in a gruesome degenerative brain disease.

And the player says, you got it, coach. And that means the people who are in charge of football, those coaches, those trainers, those owners, they bear some responsibility for protecting the football players that are under their charge. And that is a responsibility that so far they seem unwilling to take on. But look, hey, even if you disagree with that argument, you still need to consider the fact that a very, very small percentage of people who play football go on to play in the NFL and make those big bucks. Because for every one NFL player, there are hundreds, if not thousands of college players who are playing for no pay. And in this country today, there are over a million adolescents playing high school football every year. And we now know that even just playing football in high school can do enough damage to cause CTE

later in life. And this problem is even wider than that. It's not limited to football. There's evidence of CTE in hockey players, boxers, and military veterans. And that could be just the start. The science of CTE is still very young, but the disease has the potential to be a public health crisis. But since this field is so new, I wanted to make sure we get the best available information, which is why on the show today, we have Dr. Anne McKee. I could not be more excited to have her on the show. She is a pioneering neuropathologist who authored the study I referenced earlier

that showed huge rates of CTE in deceased football players. There are few people on the planet who know as much about CTE as her. So if you have any doubt that this is the straight dope right out of the horse's mouth, do horses keep straight dope in their mouth? I guess for the purposes of this metaphor, they do. Put them aside, she is the expert on this issue.

She's professor of neurology and pathology at Boston University School of Medicine and director of Boston University's CTE Center. Please welcome Dr. Anne McKee. Anne, thank you so much for coming on the show. Well, thank you for having me. So tell us just really basically, what is CTE? People have heard this acronym, but what is it? So CTE is what we call a neurodegeneration of the brain. Over time, tau builds up. It's a protein in the brain that builds up,

and it's toxic to nerve cells. So over time, it'll stop the normal functioning of nerve cells and even kill the nerve cell. And if enough nerve cells die or are affected, you start to lose your ability to think clearly or remember things. Sometimes it affects your behavior. You might become impulsive or irrational. Depression is common. Violent behaviors are common. And it tends to progress with time. So the longer you survive after these head injuries, the more severe it becomes. And how long have you been studying this condition? How long have you been studying this condition? Well, I first started out in 2003, so that was 17 years ago.

But then I really got started in 2008 when I started looking at the brains of football players, NFL players. And that's when the research really took off. I developed a brain bank, which is now the largest brain bank in the world, studying this condition. Wow. I've looked at hundreds of cases as young as 17, as old as 89. It's been an extraordinary journey. Wow. And I have so many questions just based off of that. First of all, a brain bank, that is a rather grisly sounding pair of words. What exactly is a brain bank? So a brain bank is, it's for people who want to contribute to science and who, after death,

whose families decide that they'll donate the brain of their loved one after death. And what we do is we harvest the brain. It can be anywhere in the U.S. and sometimes internationally. We have a team that will go out, harvest the brain. It'll be shipped to our center, either by plane or sometimes by car. And then we dissect it and evaluate it. We store it in an optimal condition and we make a diagnosis. We look at it very thoroughly and decide if there's anything wrong with the brain, if there was Alzheimer's disease or a stroke or an infection, or of course, we look for CTE. And it's been an

extraordinary part of our work because we have now over 800 brains in this brain. Wow. And who are the folks who decide to donate? Are these folks who maybe they're showing symptoms that might be related to one of these issues and they say, well, we should have this checked out or et cetera? Well, we definitely get brains from individuals may say before they die that I think something's going on. If something happens to me, can you make sure that my brain is donated? Other times it's family members that say, you know, he just didn't seem right. There's something that changed.

We want to see if there's something going on. But it can be all sorts of things. We get brains from medical examiners, individuals who've died suddenly or accidentally, suicides. And if the family finds out that we do this kind of work, they'll have their brains sent for that evaluation. my colleagues named Chris Nowinski, who works for the Concussion Legacy Foundation. He'll call, call a person if he sees that the person's died and see if the family's interested in this kind of contribution. It's such an incredible, just as a little aside, what an incredible donation for someone to make to science. I personally, we did a whole episode on medical body donation on Adam Ruins, everything. And as a result of that, I ended up signing up with the UCLA body donation program just because of, oh, there's a need for this. There's a need

for transparently donated bodies. And so if you're listening to this and that interests you, check out your local research university hospital in your area and see if they have a program. But so what have you discovered over those years? I mean, your work is really pioneering. If you read an article about CTE, your name is likely in it because of your work. What have you discovered over those years? Well, we've discovered a lot. It's been a wild ride. Well, we've really narrowed down what this disease looks like under the microscope. We know it's tau in a particular pattern. We know how to identify it and differentiate it from different diseases. We're looking at the clinical symptoms. Those have been a little bit more difficult to

narrow down in terms of what are specific symptoms for CTE. We've looked at a lot of American football players because that is the primary donor to our bank, probably because football is so popular in America. We get hundreds of football players. What I think has been extraordinary is that, you know, we started out looking at professional players, NFL players, but it's really trickled down. I mean, now we just get hundreds of cases of college players. We get sometimes get high school players. And I think, you know, this isn't just a professional league disease. This is something that could affect amateur players. And, you know, I do find it with every case that comes in, you know, every case hits you. Every case has its own tragic story. And you just feel this, I'm just compelled to want to find solutions to this. I want to find how to diagnose it during

life. I want treatments. And so, we just work on that day and night. And so, right now, this is a condition that can only be diagnosed after death. Is that correct? Yeah, that's the big problem. We can only diagnose diagnosed after death. Is that correct? Yeah, that's the big problem. We can only diagnose it after death. And that makes it a scary proposition for people that are concerned that they have it. But we're getting closer to ways to diagnose it during life. Blood tests, spinal fluid tests, and even some imaging of the brain. And I think there's been, you know, for me, I started out in Alzheimer's disease.

Science moves very slowly. But this disease now, it's been on the radar, let's say, 12 years, I think, on the radar, maybe only seven or five for most people. We've made a lot of progress in a very short time. I feel really optimistic that in the next five years, we'll make dramatic breakthroughs in this disease. And it would be an enormous breakthrough if you could identify it, if you could diagnose it during life. That would be huge. Yeah. Although, are you all concerned that we'll learn something that is uncomfortable to learn when we do that?

That maybe the prevalence of the disease is more common than most people might want to think? Well, you know, I think everything we've learned has been uncomfortable for people. I mean, nobody wanted this to happen. I started out as a huge football fan. I just adored the Green Bay Packers. I grew up right around Green Bay. So the Green Bay Packers were my team. I followed Brett Favre like a crazy person before all this started. And so I do understand how important football is to people. This has been bad news all around, right? Because we like our Sunday afternoons and getting away from work and just relaxing with our team. It's been fun. And this

has been really uncomfortable and inconvenient. But the only way we're going to help these players and make sure this doesn't happen in the future is by facing the truth. And so that's what I've been trying to do. Just tell the truth, the pure naked truth, and just let it lead to what it leads. Yeah. And thank you for doing that because the alternative is, even though it's uncomfortable to learn this thing, the alternative is folks suffering in silence or not knowing why they're suffering or, you know, I mean, if we're going to treat this condition at all or cure it in any way, like first we have to know what causes it and how prevalent it is and what it is. Exactly. If we put our heads in the sand, it's not going away. It's just going to affect more people. And I understand that, you know, you can, if you decide to become a professional player,

that's a, you can make a decision about that, you know, a learned decision as an adult. But, you know, we want to make sure we're doing the best thing for our kids who are often playing these games to participate in team sports or, you know, stay physically fit, all really important things. But we want to keep them safe. You know, if they're not going to make their whole life about football, we want to make sure they're in good shape when they stop playing football. So let's talk a little bit more about the specific findings. One of the things that you have found is that CTE, there's so much focus on concussions, right, on the big bell ringers,

and that's been the NFL's focus so much is reducing concussions. When people talk about it in the sports press, they're often only using that C word. But what you found, correct me if I'm wrong, or I'm just putting in my own words, that even those small little collisions build up over time, just the routine, you know, tackling dummy, you know, the body is running forward

and it suddenly stops. Those accrete over time and eventually lead to CTE. Is that the case? And if so, why? That is the case. It's the little dings, the little hits. We call them sub-concussions because they don't even cause symptoms. People play right through them. They're not even aware that they're, it's every hit,

almost on every play for a football player, but it can be the little hits in soccer that don't rise to the level of causing any symptoms like, you know, balance problems or feeling foggy or dizziness or anything. And so you're unaware of them. But what our data has shown is that those little dings that you get over, usually over a period of years, build up and eventually, in most people, trigger this disease called CTE. Now, concussions per se often accompany these little hits, right? They happen in the same situations. But it isn't the concussions. It's not the number of concussions that you have that increase your risk for CTE. It's really the length of your playing career, the number of little hits you accumulate over time. Wow. And so these are hits that the player could feel completely fine after,

like in the course of practice or a game, completely routine, like not even, nothing's gone wrong. This is how the game is supposed to be played, yet what invisibly under the surface, this sort of irreparable damage is being done? Yeah, it's sort of a gradual wear and tear breakdown to the nervous system. I mean, the brain is a delicate structure. The nerves are very delicate. They have a very fine internal skeleton. And actually, that internal skeleton is what contains tau. And over time, with damage, with the high velocity hits, usually almost a whiplash injury forward and backward and rotationally, that stretches and tears the nerve cells. And that's what causes this damage to develop over time. Our work has shown that if you play football for four and a half years, you're 10 times

less likely to get CTE than if you play longer. And if you play 14 and a half years, you're 10 times more likely to get it than if you play less. It's something like for every 2.6 years, your risk for developing CTE doubles. So that it really tells you that it's those little things that you're really not even paying attention to that are heightening your risk over time. And is this like when you when you use the word trigger is CTE, is this a condition that you get or you don't get? You know, is it is it an is it a binary or is it like a gradient? Like if I play, you know, a year of football,

am I degrading by a certain percentage, you know, my, does that make sense? Yeah, yeah, no, totally. I mean, well, clearly some people don't get it. I mean, we'll have two individuals that played the same amount of time, same position, same sport, and we'll have one person with CTE and one person without it. So we think there are other factors like genetics and maybe other exposures that contribute to the risk.

But generally, if you get CTE, it tends to be a progressive disease. So it's more binary. But in some people, it progresses very slowly. It can be very indolent. They don't really develop too many symptoms until much later in life. And then we also see players that are in their 20s that have had what appears to be a very rapid course with a lot of behavioral difficulties. And, you know, a lot of those guys have died accidentally and many at their own hands. Wow. So it really could be that even if you play for that short amount of time,

if you have the other risk factors that we don't, we're not really sure of what they are yet, but you could develop an advanced form of the disease, even if you're just playing high school or college, like, you know, semi-pro or not, or on an amateur level? Yeah. What actually, what's interesting is it's almost not important. It's, I'm sure it'll be important, but it's not as important what level you play. What's more important is how long you play. And sometimes we have people that have played youth football for 10 years and then they, and they get a 15 year exposure, even though they never went much past high school. So, you know, that that 15 year exposure, even though they were weren't even playing at what we would call high levels, is still a significant

risk because they start as a young kid and then they're just playing through primary and secondary school. They're not even playing in college and they and they have that much exposure. through primary and secondary school. They're not even playing in college and they have that much exposure. Right, right. And so that's why some of the push has been to get people to play tackle later because at the very least,

their length of exposure, the cumulative hits, the number of little hits, it's estimated to be about 1,000 a year. That varies 800, 1,200, but it's a lot of hits per year, even in the youth level leagues, even those little kids. And over time, that translates to 10,000, 15,000 hits. And when you're talking about NFL players who are playing for much longer than that,

I have here, and you can correct me if I'm wrong, that in your brain bank, you found that 110 out of 111 brains that you studied of NFL players develop CTE. Do I have that right? You do have that right. Now that's with the caveat that this is a brain bank population. That doesn't mean that 99% of NFL players are going to develop this disease. That means that in this particular population, which is enriched in people that are suspected to have CTE, right? Because the family wouldn't have gone to the trouble of donating the brain unless they had some concerns. That's a bias that exists in all brain banks. But there's been studies since that 2017 paper of ours, and they've looked at the number of NFL players that died in that same eight-year period. And if we assume that we got every single brain from every single former NFL player that had

CTE, then the risk is about 9.6%. So about 10% of NFL players. Personally, I think that's a high risk. That's the lowest it can possibly be. And then if you assume the much more likely scenario that we only got, say, 20% of the cases of CTE that died during that same period or 10% of the cases, the risk for CTE in the NFL population rises to something like 80, even 90%. So it's a significant percentage, no matter how much selection bias is in our brain bank. Right. Because, I mean, yeah, you have 111 brains. There's only so many NFL players. And so the minimum is that,

hey, this is a lot of NFL players who have this. We're not talking about there's a million NFL players walking around. Right, I think it's something like 20,000 current and former NFL players. And it was about 1, 1300 died in that period. We got 111. So that's where the math comes in.

But this is why it's so important to be able to find a way to diagnose it in life, because then we could actually get a measure of how many current or former NFL players have this condition. Yeah, absolutely. And the other thing is, I started with other neurodegenerative diseases. I started with Alzheimer's disease. I started with Parkinson's. To me, the other beauty of this disease, which is almost separate from this disease, is that I think by understanding how this disease occurs after trauma, it'll really give us a leg up to study these diseases that

appear to occur spontaneously with aging. Like Alzheimer's disease, the most common is that it just pops up in an aging person. But I think if we can translate what happens in CTE to other diseases like Alzheimer's, we may actually be able to make a real dent in treating those diseases as well. That would be, yeah, because those are diseases that are, we don't know the causes of them. So if we can get a little bit closer to that, that would be enormous. They're what we call sporadic, at least most of the cases of them. And so, yeah, maybe something that we learn after trauma will translate to being able to treat these other diseases. So there's a lot of reasons to study

this. But I'd have to say from my personal standpoint, I just don't want to see another guy come into my brain bank with this condition. It's a horrible thing. Yeah. And just talk a little bit, I don't want to, you know, belabor the point, but talk a little bit about the result of this condition or what this means for folks who have it. Like, what are the symptoms that folks experience? Well, it's interesting because in like the early stages or when people, the younger guys, it's mostly been guys. There's been a couple of cases of women in the in the literature we don't have many women's brains coming in so this is a plug for for for brain donations for women because we know it happens in women we just haven't had the opportunity and

contact sports i mean megan rapinoe if you're listening like you know consider right and we've had some buy-in from a lot of prominent female soccer players too um uh that are you know, consider. Right. And we've had some buy-in from a lot of prominent female soccer players too, that are, you know, pledging to donate their brain, like Brandi Chastain and others. But, so we need to know what's happening in women. But what happens in some guys that we've studied, and we've studied a lot, you know, notable examples, people like Aaron Hernandez, you know, we studied that brain. And, well, we know that he had a very difficult life and how much CTE contributed to that life is an unknown, but I'm sure on some level it contributed. What we see in these guys, if they present early in life with symptoms, is sort of impulsivity, poor judgment, often depression, volatility, aggression, often violent behaviors. And one of the things that I

think is most difficult is they can't control it. So they may feel very remorseful after they do something particularly violent or aggressive, but in the moment, it just comes over them and they can't control it. So, they have this lack of control of their brain. And then they can feel foggy, they can't remember things, they might lose things, memory disturbances. Those tend to come on a little bit later, but they can all be very, very devastating for the person. Yeah. And man, hearing about that makes so many things fall into place. I mean, I was just thinking about a few years ago, you know, there were a whole bunch of television shows about OJ Simpson, about those cases. And someone, I think in our writer's room

at the time said, you know, it's really weird that all these miniseries are not talking about, like, his football career. That, like, I mean, you know, we don't need to speculate about O.J. Simpson, right? Or we certainly cannot come to any conclusion about his particular case. But it kind of looks like this could be part of the story, and yet it's not, you know, it's so off.

For so long, it's been like a mystery. Oh, why did these things happen? Why? Why is he behaving this way? Right. Even the things that are not part of the famous court case. You know, wow. He's he seems to be behaving erratically.

It's those sudden erratic, really, really off the wall behaviors that are so devastating. It's not just the person who has it, but the families. So the families live with this and they don't know exactly what it is. It's frightening. It's frightening. It's hard. Imagine dealing with it. You've got to, you know, generally these guys are big, they're athletic, they're, you know, and they're not easy to handle. So there's a lot going on for families. handle. So there's a lot going on for families. How has your research been received positively and negatively? Because again, it's uncomfortable information and it's information that kind of jeopardizes some folks' business models, right? And so maybe they're structurally not disposed to take it in. How have you found it received compared to maybe other research

you've done in your life? Well, I've certainly never had research received like this before. This has been an education in just about everything. The politics of sports, the social aspects of sports. No, I've had huge amounts of pushback. In the beginning, you know, everybody thought I was out of my mind. You know, and it was certainly difficult in the early years to gain acceptance from my peers, even, that this was a condition that could affect the brain, especially in athletes and military veterans. that could affect the brain, especially in athletes and military veterans. But eventually, we got to the point where we had enough cases that we got some publications in major journals, and that has continued. You know, we cannot push the ball forward any other way than to have hard data published in good journals. And so that's always been our model.

But even though we do that, we have pockets of adversity all over the place. We certainly have adversity from people like Gary Bettman, you know, the commissioner for the NHL. This is not anything he wants to have anything to do with. I've had pockets of scientists that really adamantly and very vociferously tell me that the work is, they write review articles that basically tear my work apart. That's part of the scientific process to an extent. Yeah, it's all part of it. A review article, though, to me is not good enough. I mean, I'm writing primary data papers.

If they want to really disprove my work, they've got to come up with the primary data. A review or opinion sitting in an armchair and looking across the room just does not carry the weight. To really disprove my work, I'm saying this to all the scientists out there that are listening, you've got to come up with some primary data and get it published. out there that are listening, you've got to come up with some primary data and get it published. Right. But then, so you get pockets of individuals, you know, in Australia, various parts of the U.S. that seem to be really adamantly against the work. I think it was interesting for me last year when the book was published by Merrill Hodge with Pete Cummings, who is a colleague here at BU, and he published the book Brainwashed, the bad science behind CTE and the plot to destroy football.

So, yeah. Are you plotting to destroy football? Apparently. Are you like in league with the MLB or something like that to try to? It's a big plot. Yeah. So it's, and when you read through that book, it's, it's comical, the things they come up with. So, but you have to, and it can be hard. Honestly, it can be hard. It can be depressing and it can make you feel like you're trying to push a rock up a hill that you'll never get to the top of. But then you just come back and you see these guys, you talk to the families.

You know this work is important. You know you are getting somewhere and you just got to plot on. Yeah. Well, yeah, I thank you for doing it. I'm also curious about, we've been spending a lot of time talking about football. We talked about soccer a little bit. But when you're saying that, even, you know, it doesn't even have to be a blow to the head is my understanding. Like, it's just the force of the body stopping suddenly causes the brain to sort of bounce around in the skull. Do I have that right? Yeah. Well, just imagine the skull is basically a helmet and you've got a brain that's inside. It's tethered by the spinal cord, but to a degree, it's freely mobile inside the skull. So, if you have high velocity, sudden stops and turns, your brain is actually moving at that velocity and it can't, it's not so much hitting the skull as it's expanding. It's stretching with that movement. And on rotation, it's twisting. And that causes

the cells that make up the structure of the brain to do those same distortions, stretch and rotate, and that damages the internal structures. Got it. It's kind of like, it's almost like you're holding a bowl of jello or something like that. And like, if the bowl suddenly decelerates, right, even if it's, I don't know, it's, I'm really going to stretch this metaphor, but like if you're holding it and you run and then you run directly into something and you stop suddenly, even if the bowl doesn't actually strike the wall you run into, it continues moving while you stop. And so then it stretches and twists a little bit and it gets these little tears and things. So that metaphor is correct. That metaphor is correct. My brilliant metaphor. Thank you for vouching for my incredible metaphor. It's a little more firm than your average jello, but it is the same idea. And

actually one of the aspects of this disease is that the tau that accumulates tends to accumulate right around blood vessels. And so to push that metaphor a little further, if you think of like spaghetti or, you know, vermicelli that's going through that spaghetti and then you were to shake the jello, you would see the greatest damage around those little spaghettis. And that's exactly what happens in the brain. There's the greatest distortion where there's those two different structures, the blood vessels and then the brain that surrounds it. And that's why we think the damage tends to occur

around small blood vessels. Got it. But what really strikes me is that, you know, obviously, in something like football, those sorts of hits, once you describe it that way, those are going to happen all the time. You don't even need to get hit in the head. You just need to like sort of stop suddenly when running into something. I can see it happening in soccer too, but I also wonder just how many areas of life, like how many occupations might be experiencing something similar, right? Where else do you have concern that we might see something like CTE? So I don't think it's like people that are doing a lot of roller coasters. Even though those are big, you know, big changes in direction, it just doesn direction, on the magnitude scale, it's actually really at the low end. So people that are falling off of beds or little things, maybe operating a jackhammer.

I don't think those things are associated with a risk for this disease. We've never seen it in those people. Got it. with this risk for this disease. We've never seen it in those people. But football, you know, those guys are those are high velocity hits. They're like 100 G's sometimes. Those guys are moving at a very fast, you know, it's a lot of mass at a at a fast pace. So there's those hits are actually can be quite quite big. What I worry about is domestic violence victims. That's an area that we have not tapped at all. Of course, you know, that's going to be a little bit more difficult because the brain donors have to have consent from their families. And that may be something that families

don't want to sort of know more about. I think prisoners, people that are in prison that get assaulted a lot or, you know, there's a lot of demographics to this that and I do think we're just beginning to understand some of the populations that are affected. during combat, but just sometimes just the practice sessions, you know, the things they do to get ready for combat can put them at risk for this disease. It's almost like, in a way, it almost reminds me of repetitive stress injuries in a way that, you know, like when I was a keyboard monkey, right, doing like coding, I had to like take steps to make sure I didn't inflame the tendons in my wrists, right? Because I was doing the same thing over and over again. And so it's really these worlds where your repetitive stress is you running into something at a high speed,

right? Or just having your body or your head stop in that way over and over again. Is that a way to think about it? That that's just, we should be aware in those situations that that's something that could arise. Yeah, absolutely. That's how you should think about it. And the really curious thing about the brain is it has no pain receptors in it.

So you don't feel pain with these injuries. You feel pain in the skin on the top of your head. And there's some pain fibers around some vessels, particularly in the coverings of the brain. But the brain per se, this damage does not cause pain. So there's a lack of awareness that you're even damaging the brain. What's so strange about that, and I know this is not your field, but what's so strange, or this is maybe a little bit off, but I get headaches, though. Like, I feel pain in my brain. Right. So that makes me wonder, well, okay, yeah, good point. There's no pain receptors in the brain. So what the hell is a headache? Yeah, well, good point. But a lot of headaches are vascular or vessel related.

And so there are a lot of vessels on the top of the brain and near the brain that may feel like it's in your brain. And there's sinus, you know, sinus congestion and different things. And just some inflammatory conditions can cause headaches. So even though I said they're mostly painless, of course, people do get con, even after concussion, you get headaches. So, so there is some pain. But there's no, there's no sort of pressure or, or that, like that type of pain doesn't register.

Yeah. It doesn't register at the moment. Like when you're getting the hit, you, maybe you feel a little fuzzy or something, but you don't really feel pain and you don't see blood. So you just think, oh, it's just I'll shake it off. I'll be fine. Right. Walk it off. Walk it off culture.

Right. Yeah. Right. The comedian Gary Goleman. I don't know if you've ever seen him. He actually performed quite a lot in Boston where you are. I never get out. Oh, you don't?

Well, hey, go see some live comedy after you spent a long day in the brain bank. Comedian Gary Gellman put a very funny special where he talked about being a football player in high school and about how he described back then when he was in his, I think, early 50s now. They'd be like, oh, Goldman got his bell rung. Right. And it was just like a fun thing. Like he felt kind of fuzzy. And they're like, oh, he got his bell rung.

Okay, go walk around and come on back. And it was treated very lightly. And he's like, how fucked up is that now based on what we know now? But it's a very funny bit. I'm sure, you know, I actually, when I first started this work, I remember going into a Dunkin' Donuts with my daughter who was in high school. And there was a group of boys outside the Dunkin' Donuts selling raffle tickets or something to the football game.

And I just went up and I said, oh, how many guys have had concussions? And they were like, oh, I've had so many. And then it was like slapping. I had seven. Oh, I lost consciousness. It was like a contest. Yeah. And I understand why

you do that. Like with comics, I bombed, I bombed here, I bombed. You know, like the bad things that happen, you want to turn them into a fun, fun rite of passage. That's how you get through it. But if you're not aware that that's going to cause a degenerative brain disease, it's a little dark. Why do you think it took so long for us to reach an understanding of this? for us to reach an understanding of this.

I mean, when you know, like boxers, for example, I'm sure boxers must be an example of people who come down with this. And there was a phrase, you know, punch drunk is like a phrase that's existed for, you know, gotta be a hundred years now. Oh yeah, he's punched drunk. He got punched in the face too much. And now he's always sort of talks like he's drunk.

That's like, you know, if you're a doctor and you're hearing the phrase punch drunk, you're probably putting two and two together about like, something's going wrong in the brain here. Right. Yet it isn't until, you know, the last 10 years, as you say, that we're really treating this medically. Why do you think that is? Okay. I'll tell you why I think, first of all, boxing, you see the punches coming to the head they get you know bloody noses bloody ears it's not a it's not a stretch to think that they might be getting some brain damage you can just see the head getting impacted yes um but i know from being a football fan and even at the time being a neuropathologist you know with those helmets

they look like they're invincible they don't you know they they they're tackled but they don't act like anything's wrong they jump right up they pop up jump right up they know the next play they're not they're not confused there's no blood they don't say oh my head hurts i need to get off the field. You know, so there's just, there was just this group sort of, we all just got, I think, mesmerized by the game and thinking that it was just like video games. They could just get knocked over and then pop right back up with no, with nothing, nothing else happening. And so when I saw my first football player, which is John Grimsley, you know, at the time

an enormous football fan. I mean, I used to listen to the radio just to get Brett Favre's interviews after the game. I was, I was stunned to see this happening to his brain. And I knew it looked just like boxers that I'd, that I'd already looked at. And it was, it was stunning to me. It was, I just, it was, you know, complete revelation. Are you still that big of a football fan? No, no. I mean, you know.

It's got to be hard to be doing that work and then go root for the Packers in the evening. Yeah, and it was gradual. Over time, it just has so many different connotations now when i see those guys go down or something happens and believe me it's a violent game you know even for the knees and then you know the head uh shoulders so it just has different different uh of different vibe for me now yeah well i have so many more questions for you but we gotta take a short break we'll be right back with more Anne McKee.

You were just telling me about the first football player who came to you. I'd love to hear a little bit more about just how you came to this work and what that sort of realization was like as you started to figure out what was going on. Well, sure. So, you know, well, it's sort of philosophical to begin with. I never actually thought I'd be a neuropathologist. I didn't wake up when I was seven and say, oh, I want to look at brains for a living. So it was just something that happened gradually. I wanted to be a doctor. I was a general internist. And then I got really interested in the brain. And then I always wanted to solve the puzzle. Like, why is the person acting like this? And the closest you can get to the truth is by examining

the brain and seeing what's going on. And that was puzzle or problem solving for me. I would understand then why the person couldn't remember things or why they couldn't move their arm or something like that. And so that became, it was actually just a fascination that I had with the brain. I studied Alzheimer's disease for many years. And then one day, I had the opportunity to look at a boxer. And it was really the surprise. I'd been very obsessively looking at tau because, you know, you develop your little interests. And that was clearly my interest was tau protein. I'd studied many different diseases. There are many diseases that have abnormal tau protein. And when I saw the brain of this boxer, I just was, I'd never seen anything like it. It's like if you studied birds and all of a sudden after 20 years, you saw this species you'd never seen before. It's very exciting. And I, you know, it's devastating for the person, but exciting on a scientific level. So I was really interested because I'd never seen anything that surrounded blood vessels that affected certain parts of the brain.

I became really interested in learning more about what happened to boxers. And then it was actually about five years later that I had, I'm going to say preparation meets opportunity. And that's when I met Chris Nowinski, quite coincidentally, and also came to know Bob Cantu, both of whom asked me if I'd be interested in looking at the brains of football players, because that was something they were interested in. And, you know And I was a huge football fan, so it was like, football fan, brains, of course, I'm going to do this. It sounds great. Little did you know.

Yeah. And it was the furry first case that came in, 45-year-old John Grimsley, with this terrible disease that shocked me. And then right after that the brain of tom mckale uh lisa mckale now is you know very dear friend she runs our family family relations uh but her husband also died accidentally also 45 years old so young yes so young you know and in my business when you die with a neurodegenerative disease you expect people to be older and somehow there's there's some there's some you can you can you can that's somehow okay but um when you see it in these young guys it was just shocking and then shortly after that i saw it in an 18 year old you know just the beginnings of it and that just started me on this really just roller coaster of a ride. You know, I saw Owen Thomas, who was 21, who took his own life, played for UPenn. And I it was it was, you know,

every time it was like every single case, I'm I'm starting to think this can't actually be true, but it's just it's it seems to be true. And then you just dig farther and it's just coming on. And then it was like tens of brains and then hundreds of brains. And it's just, it never ceases to amaze me, the level of this disease and how difficult it is and how terrifying it is and devastating for the families. What does it look like when you said you looked at that brain and it was astonishing to you? What do you actually see? What does it look like?

So I'm looking under the microscope and tau is normally probably has no color, the protein tau. But we do a stain. probably has no color, the protein tau, but we do a stain. You stain the brain sections to see like nerve cells and some other cells, glial cells and blood vessels. And, you know, you can distinguish the different components based on how they stain. It's sort of like developing a photograph, you know, you have to put it in silver immersion or something like that. I don't really know exactly, but you develop it over time, or at least we used to back in the days of film. And so you develop the slide and, and when we develop it, we, we tag the tau protein, usually with a brown color or a red color. In this case, it was brown and I could just see this brown staining cells just florid all over the brain. And they were, they were just doing all these peculiar things. You know, you see them in circles and patches. And there are parts of the

brain that are affected in diseases. But in this disease, they were just, it was like they were flooded with this tau and parts like the mammillary bodies that usually don't get that much damage and the thalamus was just ruined and parts of the brainstem and cerebellum even and you know if you're if you're into this right you have to be into it it's it's just extraordinary it's like you're on a journey and you just keep you just keep pushing a door and you just see more and more and you just can't seem to find the end of this incredible maze that's just appeared before you there's a there's a lot to microscopy that's like astronomy i think it's like you're in a different universe you know you're in the universe of the brain cells yeah you look down the scope you're at you're that's what you're doing

you're really inhabiting that level of reality you You do, you really inhabit it. And I do feel like I'm on a journey when I'm like looking at a brain, you're just, you're, you're visiting different parts. You're visiting the part that has to do with memory. And then you're going to, you know, wheel over and look at the part that has to do with vision and you're going to check it all out. It's, you know, if you're into it, which I am, it's really fascinating. Yeah. I mean, it sounds like an incredible moment of exploration and discovery when you are looking through that slide for the first time and hear something that you didn't really imagine possible.

And you sort of start thinking, what is this person? Who is this person? You know, you become really kind of invested in who they were, how they were behaving. And that's the whole kind of wonderful mystery of it. And then you talk to the families and they sort of fill in the gaps and it becomes this sort of combined journey with the family and yourself trying to make sense of it all. And how, I have to ask though, you know, when you're doing this work and I love how you're depicting sort of the natural excitement of the scientist, right? Like you love the work and you're curious and you're interested and you're on that journey. And yet it's also tragic what you're, what you're seeing. How does, you know, how, how do those emotions come up for you? How does that work feel while you're, while you're doing it? You know, that's what's, this is a really intriguing question because on one level there,

it's exciting, right? It's exciting. It's a new adventure. It's a new perception. It's a new discovery. And then on the other hand, it's talking to the family, and they make it about a person. And you start to understand this very private life that this person had and their difficulties in there, you know, maybe their behavioral changes and their mood and their volatility. And then you become, you just get so invested in. And, and for me, it's actually quite fulfilling, because, you know, I started out as a clinical doctor, I sort of gave that up to look at the brain. And now it's my way of

reconnecting. And I can't make their world, the family's world better, but at least I can help them understand and come to a conclusion. And I like being on that journey with them. I feel close to them. I feel very grateful that I'm in that position that I'm in. very grateful that I'm in that position that I'm in. That's amazing. That's, yeah, that's a really singular experience. Thank you for sharing it. I do a very nitty gritty scientific question that came up to me while you were talking.

The tau protein that you're talking about, what causes it to arise or what are your theories on that level? And do you have any idea of how, you know, you're describing the tau protein sort of like distributed through this brain in a really astonishing way. How does that cause the brain to function differently? Do you have any idea of the mechanisms behind it? Well, we think that, well, the tau protein is a normal protein in the, we call it the cytoskeleton or the skeleton of the cell. So it actually helps the cell maintain its shape, just like our skeleton inside our body maintains our shape.

It also helps function. You know, there's a lot of transport of nutrients and other things along the nerve cells. So you have the cell body, which is like the business. And then you have all these tiny branches and processes that you've got to keep nourishing so they don't deteriorate. is the tau starts building up in the nerve cell and it starts interfering with that transport, that nourishment of the, especially the distal parts of the cell, the parts that maintain the connections with other cells. So we start losing our connections and our communication between cells. And, you know, we have trillions of cells and even more connections between cells. So you have to accumulate enough damage to start seeing some actual difficulties. And that's why it probably takes such a long time for this to manifest in a lot of people.

It requires toxicity to a lot of cells, a lot of their connections, to get to the point where you can't do something as well as you used to be able to do it. You know, this puts me in mind of a question that I wrestled with many years ago. I was a philosophy major in college. I wrote my senior thesis on philosophy of mind, right? And the question of how is the mind identified with the brain, right? That's a really interesting question. Yeah. It's, you know, the philosophical angle is like, it feels like something to be a person. And how is that connected to the physical object of the brain, right? And it's such a mystery.

And when you're in that position where you're looking at, you know, the brain through slides, and you're looking at the really root biology of it, and then you're talking with the person's family, or maybe you even spoke with the person before they passed away, and you're really having an intimate connection with the person that they are as well. I'm really curious about what your perspective is on that question of how is the self or the conscious mind connected with the with the brain well i think that's one of the mysteries of life uh i i am i do think they're very connected but one is clearly more spiritual and one is more physical and how that interfaces. I don't feel like I understand that either. You know, but I do think the brain, the three pound thing in our side, our skull is responsible for our personality and the way we think. It's part of our emotional network.

It's part of how we, it's so many things more than just how we count or speak. It's how we feel and how we integrate our experience in life. So, but it's a huge issue. Spirituality, the mind, the brain. God, I don't have the answer. But do you ever have, are you ever sort of struck by that where you're experiencing an emotion or a feeling and then you're like, and then you know, as a scientist, well, this is because of a buildup of such and such a molecule in my brain. Those are the same thing, right? That's the deep mystery of philosophy of mind. Do you ever find yourself struck by it?

I'm constantly struck by it. I think it's a deep mystery that's way above my pay grade. I don't understand it. Well, I honestly hope, you know, that's a question for philosophers. And honestly, I hope your pay grade is better than philosophers pay grade, because I think the work you're doing is so vital. Getting back to that, you know, again, you are, you have such a key perspective on this, where you are both talking to those families and looking at the brain and pushing the science forward. I don't want to ask you to, you know, come up with policy answers or anything like that about sports or about youth sports. I know that's not what you do, but I'm curious if you feel that the institutions around our sports, the NFL, the NCAA, which comes up much less often in this conversation and should come up more often, I think, high school sports,

football culture in general, if they've responded in, you know, how do you feel about how they've responded, about the measures that they've taken, about their institutional response to this issue or the culture? Have you been optimistic about it? Have you been disappointed? Very curious about that. Well, I think I've been struck by how much they protect their finances, how much money rules the world, how much money rules science, the influence of money on science. Those are the things I've been struck by. And for me, a person who's, I think, much more interested in, I feel a moral obligation to do this work. It's just part of me that I,

I can't stop doing this work because I feel an obligation as a doctor to try to make the world a better place. So, I don't always understand why, why they don't take on that same responsibility don't take on that same responsibility of taking care of the of the participants that made you know these these leagues who they are and that's just a a basic uh uh fact that i that i don't actually understand yeah i mean it seems to me that, and what I sort of alluded to in my opening monologue to this episode, that, you know, when you're a coach or a team owner, or especially at a university, for example, if you have a college players, those players are under your care. And if they are injuring themselves in this tragic way, that's something that you bear responsibility for and you have a moral responsibility to reduce or make sure it doesn't happen. And it does seem like a lot of folks in that position are not willing to take that responsibility on. Yeah, I would agree with you. And it's been discouraging about human nature.

I mean, it's just a fact. Yeah. Are there measures that they could be taking, especially at the high school level or younger, where I think we're, you know, especially the most concerned are there? Do you find yourself reading the sports page going like, just, just do this and you'll make this happen less often? Well, yeah, I think especially with the youth groups, we could eliminate tackle football for youth. I don't see the purpose of that. We all know that Tom Brady didn't start playing football until he was in high school and he seems to be pretty good. He didn't seem to affect his career any.

So, you know, we don't have to start with the contact so early. These kids are growing. Their brains are delicate. They're really at high risk for injury. I'd really like to see, it's, there's so many things that we could do to change youth sports to make them safe for kids and not impact their future potential as really elite athletes. And I'd like to see parents doing that. I think it's just common sense that you

don't want to injure your kid. You want them to grow to their full potential in life. And I believe in contact sports. I think sports participation is huge for kids in terms of physical development and also psychosocial development. But let's just keep the head contact out of it. It doesn't need to be part of it. Right. I mean, you get all those benefits from playing basketball, too. And you don't need to put your brain at risk. Like there's, you know, one of my favorite things about games is that we design them.

You know, I'm a fan of sports. I'm a fan of all types of games. And, you know, in the cool thing about video games or board games, things like that, is you got a new game designer. They come in, they design a new way to play, and that's fun, right? I exactly agree with you. Yeah. We did not, these sports did not come down on a scroll you know yeah 500 you know ad or bc or whatever is we made them up yeah we made them up we can change them yeah

exactly and we can change it it's very ask any game designer hey come up with something that has all the fun of football just as fun to to watch, has exactly the same drama, same pace of play, et cetera, doesn't cause brain injuries. That's your design constraint. Go to the NYU Game Lab or something where they've got brilliant game designers and they will come up with 10 different ways to do it that would result in a really great watching experience

and nobody dies at age 45. Exactly. I couldn't agree with you more. Well, maybe I can get a game designer to come on the show and lay that out for us. But I'll let you get back to the incredibly important science that you're doing. I really appreciate you coming on the show today

to take a break and talk to us about it. It was really fun. Thanks for having me. Thanks so much, Anne. Well, thank you again to Anne McKee for coming on the show. I hope you enjoyed that conversation as much as I did. I really appreciate her willingness to take that conversation to some really fascinating and difficult places. She was absolutely wonderful. And that is it for us this week on Factually. I want to thank our researcher, Sam Roudman, our producer, Dana Wickens,

our engineer, Ryan Connor, Andrew WK for our theme song. My name is Adam Conover. You can follow me at Twitter at Adam Conover. You can sign up for my mailing list and see what else I'm up to at adamconover.net. And until next week, we'll see you on Factually. Thanks so much for listening.

I don't know anything.