As the arguments rage about how best to recognise and treat brain injuries in rugby, clouds are gathering in the distance. There was fury during the summer tours when Johnny Sexton was picked for Ireland’s second Test against the All Blacks, a week after he had been withdrawn with such an injury in the first match. Meanwhile, England adopted a more conservative approach, withdrawing Tom Curry, Sam Underhill and Maro Itoje from their tour of Australia. Still those clouds gather. The appropriate treatment in the here and now of players with manifest brain injuries is non-negotiable, but it does not begin to address the wider crisis.

Last week, Ryan Jones became the latest former rugby player to reveal his diagnosis of dementia with probable chronic traumatic encephalopathy (CTE). Last month, the Guardian and Observer published features on the neurological legacy of a career in rugby for two former All Blacks, similarly diagnosed, and their families. The conditions they are suffering are not the result of concussions or their mistreatment but of multiple rattlings of the brain over many years.

There is no easy answer to the central, tragic flaw in all collision sports, which is that the more players improve, the more dangerous they become to each other. The explosion in the number and intensity of collisions that rugby has witnessed over the past 25 years or so is not the result of some conspiracy by delinquent coaches and players trying to hurt each other. It is simply the logical conclusion of collision sports, which place such premium on speed, power and fitness.

The rest is tinkering. Last year we saw the tackle count exceed 500 in a match between Leinster and Connacht. No amount of concussion management or red cards is going to make a material difference to that.

A lawsuit is under way, brought against certain governing bodies by the first generation of players to have played a full career since rugby union went full-time in the mid-90s. It is in the unfolding of their various conditions that the fate of the sport will likely be decided – and for which governing bodies should be preparing now, regardless of any fault.

The best-case scenario is that the players’ diagnoses of probable CTE are wrong. The brain damage they have suffered is on the scans and undeniable, but are the resultant conditions degenerative? In other words, will they die of them?

Brain scans of possible disease or damage in a clinic.
Diagnoses of probable chronic traumatic encephalopathy are being seen in American football players in their 20s. Photograph: Andrew Brookes/Getty Images/Image Source

Only time can answer that question, but the experience of American football, a few decades ahead of both codes of rugby as a full-time collision sport at elite level, is not encouraging. Dr Adam White, executive director of the Concussion Legacy Foundation (UK), has led the research of the CLF into the families’ experience of CTE on both sides of the Atlantic.

“I think we are looking at the same issue,” he says. “I don’t believe there is any evidence or logical explanation to suggest rugby is going to be any different. We may get a slightly later onset, given American football used to start heavy contact at age five, but we’re seeing teenagers and people in their 20s with CTE over there.”

One of the characteristics that marks out CTE from other forms of dementia is the intersection between its typical age of onset and the profile of its typical sufferer. The results can be dangerous – and not just for the sufferers. “We’re talking primarily about athletes and veterans,” says White. “They are younger, bigger, stronger, fit and able. They are indoctrinated in a culture where to thrive they must be tough, strong and aggressive. And then we mix in dementia …”

If some or any of these conditions reported by players turn out to be degenerative, that storm in the distance is heading rugby’s way. When the story broke of the crisis in 2020, I wrote about my family’s own experience with early-onset dementia. In 2019, after years of escalating difficulties with memory, executive function and emotional ability, my wife was diagnosed with Alzheimer’s at the age of 49.

In October last year, after a seizure in the small hours one morning, she was taken to hospital and thence to a nursing home, where she now requires full-time care. The search for a home for her was already under way by then, but the vast majority were unable to take her.

Geoff Old and Irene Gottlieb-Old at a New Zealand players’ reunion in 2019
Geoff Old and Irene Gottlieb-Old. She has tried to set up a centre in Auckland for the treatment and support of affected players and their families. Photograph: Courtesy of Irene Gottlieb-Old

The underlying issue, sometimes not even unspoken, is the very real responsibility homes have for their residents, who are frail and vulnerable. They could not accommodate someone in her early 50s known to exhibit what is euphemistically known as “challenging behaviour”.

My wife is closer to five foot than six and she did not play international rugby. If she is too much for most homes to take on, how many will consider someone who does answer to that description?

She suffers from a rare and aggressive form of Alzheimer’s, which is different from CTE. Her deterioration has been swift and unanswerable. There is every chance the diagnosed players will follow a less precipitous decline, which might respond to treatment and good living, if they follow a decline at all. But for those who do turn out to have CTE, which is by definition degenerative, the need to find accommodation will be as much about the safety of their families as a question of practicality.

Irene Gottlieb-Old, wife of the former All Black Geoff Old, spoke to the Observer of her attempts to establish a centre in Auckland for the treatment and support of affected players and their families. That project remains on hold but represents the kind of first steps a governing body might take to address this crisis. A subsequent announcement of a partnership between the Alzheimer’s Society and the players’ unions of football, rugby and cricket looks like an actual step in the right direction.

But only a step. There will almost certainly come a time when highly specialised units will be required just to house those former players with the worst of it. Rugby is deluding itself if it thinks this is going away. How refreshing if governing bodies could step up to help players now, rather than wait to see if a court of law finds them liable.

“I hope the RFU and World Rugby are in the background thinking: ‘How do we syphon off funds to put in reserve for the care and support these players are going to need?’” says White. “At the moment there is no such place set up for this. CTE [in rugby] is quite new. If we could call for anything it would be to plan ahead. We might not need it today, but we probably will in five or six years.”

Carl Hayman, the former All Blacks prop, told the Guardian that he has been paying for his own support. He also acknowledges that he is lucky enough to be able to fund it himself. He wants to speak out for those of his colleagues who might not be able to.

Dementia care is ferociously expensive, and the costs only escalate as the condition deepens. That does not make “support the players” an easy answer to any of the problems that feel as if they are assailing rugby from all sides, but it is a clear answer – and one that will need supplying sooner or later.



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