He is a self-proclaimed football fan of the New York Giants and claims he has always had an interest in the injuries that occur in football. He is also an epidemiologist who ran his own successful company doing clinical trials, outcomes research, and epidemiologic studies for pharmaceutical companies. Now in retirement in his early 60’s, Jeffrey Markowitz, Dr.P.H., decided to combine his interest in epidemiology, biostatistics, and his love of football to pull together and analyze three years of data on concussions in the National Football League (NFL) from 2010 to 2012.

Self-Published Book

The result is a self-published book he has written in collaboration with his daughter Ariana Markowitz entitled “Pigskin Crossroads: The Epidemiology of Concussions in the NFL 2010-2012.” After the introduction, which Ariana with a degree in political science researched and wrote, the book chronicles the evolution of increasing awareness of the problem among the players, observers, and the NFL itself, and the second half of the book combines data from at least 6 separate sections of the NFL website to examine the risk factors for concussion among NFL players.

According to Markowitz, “concussions are a serious problem and the existing data are not very good. I wanted to try to fill the gap.” He added that, “reliable data on concussions were not easy to come by. There are no downloadable databases with this information. I spent thousands of hours doing this work.”

Independence

Markowitz told the Monitor he used his own funds to pay for the research and publish his results and says he is independent of the NFL. This is apparently a critical point in the history of this problem because previous researchers were affiliated with the NFL and came under fire for this very reason. Their work was discredited even though a dozen or so papers were published in top notch journals, according to Markowitz. Because the validity of the earlier work has been questioned, “it’s impossible to know the truth” says Markowitz. He himself initially suspected that the NFL-affiliated reported rates of concussions were
rather low.

Data Validity

Since he used NFL data for his analyses, Markowitz devotes a section of his book to defending the validity of the NFL Injury Reports on which he based his analyses. He says he found the validity to be “very good” but, because of data issues, examined only the first concussion that a player may have had during each of the respective three years of interest.

Randomness

According to Markowitz, “a lot of people believe that concussions are random events, and this is really untrue.” In his book he adds, “Perhaps the single most important thing that these results mean to me is that concussions in the NFL do not occur randomly.” Asked which findings best establish this truth, Markowitz told the Monitor that players in “speed” positions have higher concussion incidence rates than players in “non-speed” positions such as offensive and defensive linemen. He said that other studies of mortality have shown the same result with deaths due to neurodegenerative disease being higher in players at speed positions.

Other Findings

Other findings in the book are that concussion rates vary by team, week of the football season, winning and losing games, and by intra- or inter-divisional play. Other variables that people have suspected might be important, such as day of the week the game is played or whether the the game is played on grass or artificial turf did not turn out significant in these descriptive analyses. 
 

Seeking a Broader Audience

Markowitz told the Monitor he wanted to publish a book rather than journal articles because he wanted to reach a broader audience than is often reached by journals. His approach may be paying off already as he says family and friends bring up the book to him and he has been invited to serve on a panel at Columbia University to discuss an upcoming Public Broadcasting System program on October 8 entitled “League of Denial—The NFL’s Concussion Crisis” which is based on a book of the same title.

Markowitz says he has had no contact with anybody from the NFL since he started working on the project four years ago. He sent a copy to the NFL Commissioner and to the Players Association but claims he has had no feedback. (See related story—An Open Letter to the Commissioner). He credits the NFL with funding research on concussions, including $60 million last year, but he says this research has been largely about identifying the problem and looking at treatment. Very little of the research is aimed at prevention.

Next Project

Markowitz said he is already at work on his next book which will examine injuries in the NFL more broadly using outcomes such as missed games and the incidence of season ending or career ending injuries. He says it will be an examination of the epidemiology of the most serious injuries, not only concussions. 

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