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Sixty minutes into the best rugby union Test of the autumn, between Ireland and New Zealand, Brian O'Driscoll left the field. He was not bleeding and he had not broken any bones or torn any tendons. Yet his injury was, potentially, far more serious. He was concussed.
O'Driscoll did not want to go off and definitely would have tried to go back on but that is why the decision needs to be taken out of players' hands. Ireland were 12 points up, 20 minutes away from a first win against the All Blacks. His team needed him. Plenty of times in the past the Irish centre had played on after suffering similar blows. When O'Driscoll's career began, concussion was something you shrugged off. Time was when he would have been feted for doing exactly that. If his exit was a turning point in the match, it may also have been one for the sport.
O'Driscoll is 34 now and bears little resemblance to the player who made his debut in 1999. The International Rugby Board (IRB) says that in the past 15 years there has been, on average, a 10% increase in player weight across positions in international rugby and a 5% drop in the average time for the 10m sprint. Over the course of O'Driscoll's career, players have become bigger and faster and learned to hit harder and more often. In the same 15-year period the average number of tackles per match has risen from 160 to 220. Rugby has changed. No longer a contact sport, it is a collision sport.
How rugby union players' size has increased. Check out the full interactive here. Graphic: Paddy Allen for the Guardian
James Robson has been around international rugby even longer than O'Driscoll. He has been Scotland's doctor in more than 100 Tests and toured six times with the British & Irish Lions as their chief medical officer. Robson thinks there is a "sea-change in attitude" about concussion. There was a time not so long ago, Robson says, when a concussion was seen "as a badge of honour" by the players. "It used to be a joke." Now, he says, it is neither. "Concussion," Robson says, "is singularly the most important topic in rugby at the moment."
Robson has been working with Dr Willie Stewart, a neuropathologist who has done extensive research into the links between rugby and long-term brain damage. Stewart has found evidence of chronic traumatic encephalopathy (CTE) in the brains of retired players. CTE used to be known as dementia pugilistica, the boxer's disease. Stewart has said that: "What we are finding now is that it is not just in boxers. We are seeing it in other sports where athletes are exposed to head injury in high levels. Those sports include American football, ice hockey and also now I have to say I have seen a case, the same pathology, in somebody whose exposure was rugby."
O'Driscoll's uncle, Barry O'Driscoll, served for 15 years on the IRB's Medical Advisory Board, until he resigned, reluctantly, in 2012, in protest at the way the board was handling concussion. He is at the far end of a spectrum of opinion on the issue. "It wasn't a knee-jerk reaction," he says. "I didn't wake up in the morning and see the light. It was a gradual business." Barry O'Driscoll was one of the IRB's representatives at the Zurich International Consensus Conference for Concussion in Sport, held every four years. "Each time we went every bit of research was showing us a little bit more about what was happening. And each time the research got more worrying." He is keen to stress that the IRB has done, and continues to do, excellent player welfare work in all other areas but he is equally clear it has "got this one very, very wrong".
At the centre of the debate is the Pitch-side Concussion Assessment (PSCA). The laws of rugby stipulate that any player who is clearly concussed should be removed from the pitch. But under the PSCA any player who is merely suspected of having concussion has to be removed from the pitch to undergo a five-minute assessment by the medical staff, who decide whether he is fit to return. The IRB says the PSCA is a triage tool. It is designed to allow medical staff time to diagnose whether a player is concussed. Before it was introduced, the IRB says, its statistics showed 56% of players who were confirmed as having concussion after the match had been allowed to return to play. In the first year of the PSCA trial that figure fell to 13%. The accuracy of that number – 56% – has been questioned by Barry O'Driscoll. But still, the IRB says, the PSCA is working.
Not everyone is sure. Robson's view, for instance, is that five minutes simply does not give medical staff enough time to make a diagnosis. O'Driscoll goes further. There is, he says, a fundamental flaw in the IRB's thinking. If a player needs to undergo a PSCA, he must, by definition, be showing signs of concussion. And as soon as he is showing symptoms, he should not be allowed to play on. "For many years now," he says, "research into concussion has made it clear that anybody suspected of concussion, showing any signs or symptoms, should come off the field and should not go back."
The IRB's research is based on more than 750 matches in which the PSCA has been used since the global trial started. It is, O'Driscoll argues, "a clinical trial taking place on a rugby pitch". He is convinced that in the future the IRB and the unions will face lawsuits from players who were unaware of the risks they were taking, just as the National Football League has in the USA. "My feeling is that as a sport we have a responsibility to accept that this could be very, very damaging for the players," he says.
O'Driscoll is a passionate man. Robson is more moderate but he, too, is uneasy that the PSCA may allow concussed players to return to play. "Initially I thought that the gold standard we had arrived at was 'if suspect, treat as'," Robson says. "So if you suspected that somebody was concussed, you should just treat them as if they are concussed, end of story. To me that is the gold standard because you are not allowing anybody back on the pitch who might be concussed." The PSCA, Robson feels, has become a sticking point. But he is still optimistic. "People are changing their views; whether they are changing their views quickly enough is open to interpretation. The hope for me is that we are moving towards a consensus."
While professional rugby union is slowly moving towards that consensus, the amateur and youth games lag behind. And while the two tiers of the sport present different challenges, the links between them are inextricable. "The young players," Robson says, "are reproducing what they see on TV. It is cascading down. The dedication that has affected our top players since professionalism is having to be reproduced lower down the scale if people, players and coaches are wishing to be successful." Young players are also stronger, faster and hit harder. But they do not have the medical support available to professionals and, more importantly, their brains are far more vulnerable to damage.
"The IRB and the Rugby Football Union [RFU] are fixated on the elite level game because that is their income stream," says Stewart. "But to be honest, we really need to focus on grass roots because that is where the big problems would be. They don't have the medical support or the medical staff, the MRI scans and CT scans on tap. Kids running about on a Saturday afternoon have just got their parents and coaches and that's why we need to be so cautious."
Professional rugby allows up to 15 minutes for treatment on a cut but only five minutes for the assessment of concussion. "The IRB has to understand that people try to reproduce what they are seeing on TV," says Robson. The IRB says "a cultural change is required" in grass-roots rugby, a community which includes hundreds of thousands of players, parents and coaches. But how do they plan to bring about change on such a scale, when they are struggling to get their policy straight at the professional level?
The professional game has a lot to answer for
"The professional game," says Peter Robinson, "has a lot to answer for." In 2011 Peter's son, Ben, died while playing for his school, Carrickfergus Grammar. Robinson believes the IRB has not been swift enough to confront concussion or strident enough in the action it has taken. The coroner ruled that Ben's was the first death of its kind in the UK. But it was not the first serious schoolboy head injury. In 2009 a 16-year-old, Jay Ryles-Jenkins, collapsed after playing a game for Sheldon School in Chippenham. He spent two months in a coma and two years in a special care unit. Since Ben's death Peter has devoted himself to a campaign to try to improve concussion awareness and education in schools, to ensure that nothing like this can happen again. "You can see," he says, "that, if we didn't keep up the campaign, it would all go into the ground very quickly."
Robinson is not the first to raise this issue. He has a copy of a document called Making Rugby Safer, published in November 2002 by the Eastern Pennsylvania Rugby Union. It states that: "Those supervising the athletes need to recognise the potentially life-threatening damage that can be inflicted when a second concussion is incurred before the athlete has recovered from the first concussion." The document is describing Second Impact Syndrome, the condition which killed Ben. "Here it is in black and white," says Robinson. "You would think the IRB would have looked at this at the time and said: 'That is a really good policy, why don't we take that on board?'"
At the youth level concussion is a question of life and death, a fact that the IRB – and the Rugby Football Union – are reluctant to acknowledge. The IRB feels that, given the debate around the issue, it cannot be any stronger or more succinct in its summation of the situation than this: "We have concerns that repeat concussions could shorten a player's career and may have some potential to result in long-term neurological impairment." Robinson scoffs. "Could shorten a player's career? They're right, death can fairly shorten a career."
This is the first thing Robinson wants to see changed. He has printed up a range of diagnosis cards, which state in bold, red text "concussion can be fatal". The short, sharp, shock of the message, he says, is essential because it reminds a coach, referee or parent exactly what is at stake. The reason he wants the IRB to be frank about the risk of death is that he thinks that, if a coach reads those red letters, he will "take a step back and think: 'It's only a game.'" Similarly, referees have the power to remove players who are clearly concussed. But all the anecdotal evidence suggests referees are reluctant to do this. Which referee would want to tell a team that their best player has to come off when the scores are level and there are minutes to play in the big match?
The IRB realises that "education is key". But education couched in such bland words – "may shorten a player's career" – is less than effective. It runs a campaign called Recognise & Remove. The posters list the signs of concussion but say nothing about the risks. This, then, is an example of small and simple change which the IRB could make – and which the Irish Rugby Football Union (IRFU) has already have made in its new grass-roots campaign – to improve concussion education and awareness.
If anything, there is a body of opinion that the risk is being over-stated, that such warnings are tantamount to scaremongering. More than one administrator says, off the record, that "statistically you are more likely to die on the way to the match than you are playing in it". Stewart describes that as a "phenomenally flippant" argument. "When you are driving down the road you put a seatbelt on even though the chances of hitting a car are fairly slim." The risk in rugby, Stewart explains, is a very small one but has a potentially massive impact.
A second, bigger change, that the IRB and unions could push for would be to make concussion education mandatory for all school players, coaches and parents, as it currently is for IRB registered referees. At the moment anyone who wants to become an RFU-qualified coach has to complete the IRB's Rugby Ready course. It does contain a section on concussion, with a screen-grab of the Sport Concussion Assessment Tool (SCAT) card used to identify the symptoms, and then a single multiple-choice question, which reads: "Which of the following are symptoms of concussion? Headache. Dizziness. Difficulty concentrating. Drowsiness."
The answer, of course, is all four. Get it wrong and you simply take it again and again and again until you have earned a green tick. More in-depth material is available on the IRB's player welfare page but you have to go looking for it. They seem to be relying on players, parents and coaches to educate themselves. Robinson has found that many of the administrators he has discussed this with have not been receptive to the idea of mandatory education but resistant to it.
"Effective is not the same as mandatory," says Simon Kemp, the RFU's head of sports medicine. "And from an education perspective, what we need to do needs to be effective above everything else. So I wouldn't want to get hung up on whether education is mandatory or non-mandatory. The question is more: is it effective?"
The RFU has an answer to that. In 2009 it launched the Use Your Head campaign. "We sent out a quarter of a million letters and posters around clubs," says Dr Mike England, the RFU's game development medical adviser. "Two years later we did some research to find out what impact we had on awareness. We found that 12% of 16-to-18-year-olds were aware of the Use Your Head campaign." Remarkably England says Headway, the brain injury charity the RFU works with, "were amazed that we had that level of success". A figure of 4% to 5%, England says, would have been considered a decent result.
The RFU's 2009 Use Your Head campaign. Screenshot: Public domain
The failure of these campaigns is easily explained. "When you get a subject that is as important as this it has to come from the top," says Robson. "And to me that means the government. They are responsible for the nation's health and that is what we are talking about, the health of the nation's young people."
The IRB, the home unions, are administration bodies, never intended to run public health campaigns. England points out that "this is a huge population that we are trying to educate". It includes newcomers, parents who may do a little volunteer coaching and "the old-school group, who have that ingrained thing of 'concussion in my day was not taken seriously, so why would I take it seriously now?' It is a culture and changing a culture is not something you can do overnight."
The strongest response to Robinson's campaign has come from politicians. In Northern Ireland the education minister, John O'Dowd, wrote an excellent letter on the topic to every school in the country. The Irish Rugby Football Union has since launched a new concussion awareness campaign, which explicitly states that there is a risk of fatality.
In Scotland the education minister, Mike Russell, was similarly receptive. His department have been working with the Scottish Rugby Union, Stewart and Robson on their own campaign, which will be launched in the new year. In England though, things are moving slowly. The department for education only recently agreed to meet Robinson after months of badgering. The Labour MP Chris Bryant has already met him and is considering launching a parliamentary inquiry into the subject in the new year.
View from the US
The most irritating thing, Robinson says, is that the UK and Ireland lag so far behind the US. "There is no doubt that it is a subject that has been brewing in America for a bit longer," says Stewart. "And that is not that they haven't met with resistance. But it is parent-power that turned the corner. Parents and players demanded to get better information" – parents like Peter Robinson and Ben's mother Karen Walton.
In the United States 49 of 50 states have passed what is known as the Lystedt law, which makes concussion education mandatory for school parents, players and coaches; only Mississippi is yet to do so. The law is named after Zack Lystedt, a schoolboy left disabled after suffering a concussion while playing American football in 2006. The Lystedt law has three components. The first is that every year school athletes and parents read and sign a concussion information sheet. The second is that, if an athlete is suspected of having concussion, during practice or play, he is removed at once from play. The third is that the athlete cannot return until he has been cleared by a licensed healthcare provider who is knowledgeable about the management of concussion.
Dr Stanley Herring, chief medic with the Seattle Seahawks, was one of the architects of the law. He was an early proponent of it and an active participant in getting it passed in those 49 States. He likes to say that he "knows all his state capitals now," having spent so much time touring them, pressing his case with politicians. He is unsurprised to learn that the RFU's education campaign has had such a limited impact.
Dr Stanley Herring, right. Photograph: Elaine Thompson/AP
"We tried the same thing here," Herring says. "We had an education program first, a very robust state-wide education program in Washington. I personally spoke to over 1,000 coaches and athletic directors and we criss-crossed the state and handed out materials." What they learned, Herring says, was that education alone did not work. The first lesson was that the take-up was inconsistent. "There would be certain schools who would embrace a program completely. They might have a coach or a director of sports who was interested, or who had suffered a tragedy, but it was not uniform." The second lesson was that the progress they made did not last. "It was perishable. If that coach got a different job, then the concussion program went with him or her." They ended up with "a patchwork that was not sticking".
Herring and the team behind the Lystedt law realised that "schools and school districts are rule-driven organisations. We realised that without the legislation we were unable to get consistent, durable implementation. It just didn't work." One of the key factors in the success of the law, Herring says, was that they had the full support of the NFL.
Herring believes that, if viable, the UK should consider a similar law. Where the US has the Lystedt law, the UK and Ireland could have Ben's law. "Concussion," says Robinson, "should be on the syllabus." There should be a sporting equivalent of the green cross code, or cycling proficiency test, and it should be mandatory for everyone who plays sport at school. The NFL threw its weight behind the Lystedt law. How many children have to die before the rugby authorities are willing to do the same?
The IRB says concussion is a "complex and emotional topic", that its approach is "based upon evidence-based research and international best-practice, not individual opinions". No one, not Robinson, Stewart, Robson or Barry O'Driscoll, is using anything other than "evidence-based research". One is a father who has lost his son. One is one of the country's leading neuropathologists. One is an ex-Irish international and former member of the IRB's own medical advisory committee. And one is perhaps the most experienced rugby doctor in the world. How many experts, in how many different fields, does the IRB need before it starts considering "individual opinions"?
People have asked O'Driscoll what he was trying to do. Was he trying to ruin the game? They have said similar things to Robinson. Robson and Stewart have both been told they are scaremongering. But all four love rugby, a game each of them played. They simply want to make it safer. "What would be scary for parents," Robson says, "is if we were trying to sweep this under the carpet. Sport carries a series of risks. What we are trying to do is minimise the risks that we recognise. People should not be scared by that. They should be reassured. What they should be scared of is people saying 'there is not a problem' or that 'our sport is risk-free'."
As Herring says: "Awful things happen in sport that we can do nothing about but, if there is an opportunity to prevent tragedy, then that is an opportunity you do not want to miss." Ben Robinson's death was preventable. It is too late for him. But there is an opportunity to do something now to stop this happening again. Is rugby going to take it?
Ben Robinson in his team line-up for Carrickfergus Grammar. Photograph: Stephen.McNamara@IRFU.IE/©Robinson Family
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