This morning saw headlines reporting the publication of an open letter to MPs calling for a ban on contact rugby in schools. The letter argues that the high impact collisions in rugby lead to a number of serious injuries including concussion and fractures. For a child that plays a full season of rugby there is a 28% risk of experiencing and injury and an 11% risk of concussion.
These high numbers may seem to warrant a ban on full contact rugby as the letter argues. Indeed, the expected harms that befall a rugby playing teenager may be much higher than those associated with other prohibited actions, such as the use of cannabis. Rugby may therefore be over a ‘threshold’ required to enforce a prohibition on contact rugby in schools. Such a threshold might exist where the marginal costs of enforcing a prohibition were less than the marginal benefits. The costs may be quite low as schools would presumably be compliant with the ban, while the benefits are high in terms of harms avoided. However, this is obviously not how prohibitions are worked out; the marginal costs, for example, of a prohibition on recreational drug use are arguably very high relative to the potential benefits since the ban is particularly ineffective as a harm reduction strategy.
The choice then is political. The median voter enjoys rugby and sees it as a part of their cultural heritage. Opponents of contact rugby may be more likely to lie at one end of the political spectrum and have little effect on sports policy in a representative democracy. For many people the perceived loss of a cultural institution in schools, the loss of liberty for their child, or the overreach of the state is a great cost. (Just view some of the comments on today’s news reports). Even in the face of strong evidence of harms, many are likely to be recalcitrant in their views, and even be annoyed that evidence was presented at all. Prof. David Nutt discovered this the hard way when he was fired from the Advisory Council for the Misuse of Drugs for comparing the risks associated with ecstasy alongside those of horse riding.
Nutt’s strategy is the correct one though. To make informed choices about the policies that are chosen from amongst the set of possible policies in any given context one must be able to compare them. People are well aware that full contact rugby carries risks, but for most people they have never had personal experience of any life changing risks from the sport. Saying that there is a risk of 1 adverse event every ~4 exposures is potentially meaningless. But add in the information that horse riding carries an equivalent risk of 1 in ~350 exposures and ecstasy 1 in ~10,000 exposures and individuals are better prepared to understand the risks.
When considering investment in healthcare technologies, a benefit of 10 QALYs, or cost-effectiveness of £10,000/QALY is meaningless in isolation. The choice to invest takes place against the background of a myriad other choices. Trying to implement harm reduction strategies in sport or elsewhere is the same. When placed alongside other potentially harmful activities rugby appears to be one of the highest risk and the costs of prohibiting full contact would be small, thus the burden of proof would seem to fall on those who oppose any prohibition. However, I would suspect that the letter as currently written would have little impact on many people’s views and therefore little impact on public consensus or policy.