World Rugby’s Dr Martin Raftery: You can never eliminate risk

Following Dr Bennet Omalu's interview with The Irish Times on June 3rd, when the neuropathologist renowned for his work on chronic traumatic encephalopathy (CTE), the brain disease caused by concussion, called for a global ban of contact sports at underage level, World Rugby requested a "right of reply".

They had two chief points of concern; they claim the evidence, particularly with regards to injury rates, counters Omalu’s argument that rugby “can never make [children] safe. You can never take away the head from rugby or boxing or American Football. We need to let people know that. That is why potentially dangerous games should only be for adults.”

Secondly, the governing body expressed concern about Dr Omalu's understanding of the Head Injury Assessment protocols, despite Dr Willie Stewart, a member of World Rugby's concussion advisory group, stating the current review process for HIA cases is in "tatters".

Dr Martin Raftery, World Rugby's chief medical officer, agreed to address Dr Omalu's statements and answer questions from The Irish Times on the current state of rugby's HIA process.

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[ you stated last year that you “really think” rugby is a sustainable sport ]

Dr Rafferty: Dr Omalu is entitled to have an opinion but that's exactly what it is, his opinion. It is not supported by evidence or expert groups. If you go back and look at people talking about contact sports in children there is not a lot of support in the scientific literature; the American academy of paediatricians in 2015 didn't recommend banning contact sport. The Berlin concussion consensus expert group, which is made up of 32 members from a variety of specialties, they didn't recommend banning contact sport for children.

While all that says contact sports shouldn’t be banned, it doesn’t mean that we don’t have a responsibility for reducing the risk.

Back in 2012 we started and we continue to push the point that we need to minimise the risk to playing rugby and that’s what we will continue to do.

But we don’t think there is any support whatsoever for the banning of contact sports at under 18.

GC: Dr Omalu stated rugby can never make the head safe, and he noted entry into the military is not permitted until people are over 18, and he compared rugby to “adult sports” like sky diving. What is your response?

DR:You've got to put things in perspective. If you look at the United States there are over 500,000 accident and emergency treatments for children injured in bike riding incidents, of which 750 deaths occurred from head injuries. Are we going to call for a ban of bike riding in children or do we try to minimise the risk by wearing helmets? You can never eliminate risk in life. That's what people need to understand. Rugby's responsibly is to minimise that risk.

GC: Dr Omalu, when asked about the Head Injury Assessment (HIA), stated: “To subject a player to a neuropsychiatric test and tell him you have not suffered brain damage is malpractice. But we continue to let it happen because we have some type of infatuational bond to these games, where we allow these games to take over our lives and our way of thinking.” He spoke about confromational intelligence and cited the Hippocratic Oath: First, do no harm. What’s your response?

DR:The responsibility in the sports is to protect the players as much as possible. When people like Dr Omalu make these statements, we say, okay, what should you do? Because there is no perfect diagnosis for concussion. So what do they want us to do? We need to take a sensible approach. The experts in Berlin said the Scat 5 is the best available pitchside assessment.

The 34 experts who made up the scientific committee came and clearly said they supported pitchside assessments of concussions. So, do we listen to the experts who include neurologists, neurosurgeons or one neuropathologist who doesn’t see people who are alive? Dr Omalu doesn’t see active patients. He is not trying to make decisions on the sideline. We are trying to protect the players so we use the best available tools that the research tells us are working. And then we test it to make sure it is getting even better.

If anybody can give me the magic bullet I will take it with open arms. There is no perfect diagnostic test.

GC:Dr Willie Stewart did come out recently and say the HIA and its review process is “in tatters”. I know an expert group from America was hired to in March to review the system, what came out of that?

DR: First of all if you look at Willie’s statement he said the review process is in tatters not the HIA.

GC:They are clearly linked, no?

DR:It was an emotive way of saying . . . but I think he knew we had organised a review of the process so we knew it was suboptimal. We will be releasing a new process around how the [HIA case] reviews are done. We will be incorporating independence in those review processes. Willie was only saying what we knew and had already moved on it.

GC:Can you give us more information on that?

DR:There will be a big focus on continued education and a review of the process with independents involved at a number of different levels.

GC:We have seen that the review process in HIA cases is not working . . .

DR: No, that’s not right. A couple of them have not worked. Look at the data, we have had over 2,500 HIAs done and we have had probably five review processes of which some of them haven’t been optimal.

GC: You have previously stated the HIA is working to “identify which players should be permanently removed from the field of play or temporarily” but we are seeing players go off, come back on and still have concussion issues thereafter (like Beauden Barrett and George North). Is the effectiveness of the HIA in question?

DR: You have to step back and look at the numbers. They are isolated incidents and I accept with some of them there have been compliance issues and with some of them [the HIA] hasn’t picked up concussion.

But go back to the critics and they will tell you there is no perfect system for diagnosing concussion, anywhere, not the sideline or the office.

Is it working? Why did we bring in the HIA? We wanted to bring in a recognition of concussion and improve the sideline management of concussion. The data now shows us that the recognition of concussion on the field of play since 2012 has increased four times. Is it perfect? Of course not.

If anybody can give me the magic bullet I will take it with open arms. There is no perfect diagnostic test. We know it’s flawed but what can we do? We’ve got to use what’s best available.

Do these people want to go back to what we had before? Do they want to leave over half the people with concussion on the field? Do they want to go back to not even recognising three out of four people with a concussive episode. We recognise more and manage these people better. It is all about improving. It is not perfect.

GC: In October Frans Steyn was red carded for a high tackle on Johnny Sexton. As Leinster coach Leo Cullen stated that night: “Johnny breezed through the HIA” and returned to the field within five minutes. Is it possible to conduct a HIA in four minutes?

DR: That is a compliance issue. No, I’m happy to say four minutes is not enough time to complete the HIA properly.

GC: This feeds into the tackle law. Last year World Rugby examined the tackle technique, where are the rule makers currently on this issue?

DR: There was an increase in sanctioning for high tackles. The number of yellow and red cards has more than doubled. There were zero red cards for high tackles in the first three months of 2016, in the first three months of 2017 there were six.

With the technique [tackle law] we wanted to get the best people in the world, and they are the elite defensive coaches, so there has been a delay as we wanted to gather information on what tackle is the poorest technique. We have go that information now and we will be having a working group come together in September. It is more difficult than we thought to get the experts together but that is going ahead.

GC: Finally, just going back to something Dr Omlau said; we are potentially going to see similar damage to the brains of rugby players as he witnessed in deceased NFL players, and that “society will suffer if we do not protect the intellect of our children by shielding them from contact sports.” On medical and ethical grounds do you disagree with what he is saying?

DR: I’ll point you back to bike injuries. There are far more bike injuries, four out of five presentations to casualties are not sports related. I’m not denying that head injuries are important. As a sport we need to minimise the risk in a systematic and, what I believe, in an appropriate way by raising awareness, improve recognition and move on to preventing injuries. We can never eliminate the risk.