THERE is always one figure at ringside who never hopes for fireworks. The knockouts, the punishment, and the back-and-forth drama all create a heady cocktail for the assembled throng come fight night. One essential seat, however, that’s always allocated at the coalface of the action is reserved for the doctor responsible for the welfare of those in battle. 

For the ringside physician the stakes could not be higher. Crucial, and potentially life-saving, decisions are required to be made in an instant, judgments that have to be entirely removed from the pressures of a crowd baying for blood and a fighter too brave for his own good. The fact that Dr Nitin K. Sethi – who was interviewed by Tris DIxon for his book, Damage – fulfils this role while operating as a highly respected neurologist places him in a unique and invaluable position when discussing the brain health of boxers. He spoke to Boxing News about his work to create a safer sport.   

How did you become connected with boxing in the first place?   

I’d just reached New York City, I was actually born in Buffalo, New York, but was raised in India and I came to New York for my residency in neurology. I didn’t really know anybody so I happened to pass by a boxing gym, and that’s how I found boxing.

I started boxing myself and in my role as a neurologist I was very passionate about Traumatic Brain Injuries (TBIs) and concussions. So at some point I wanted to mix my love for boxing with my passion for Traumatic Brain Injuries so I applied for to the New York city Athletic Commission and started working as a ringside physician. And in 2015 I was appointed the Chief Medical Officer for the New York City Athletic Commission, and that’s the position I serve in right now.   

Dr Nitin K. Sethi on boxing
Dr. Nitin K. Sethi

I can see from articles you’ve had published and previous interviews that you hold some strong views about making boxing safer.   

I do, because as I see boxing I look at an iceberg. And people think an iceberg is what you see out of the water, and that’s probably the Acute Traumatic Brain Injury. Everybody talks about it, every so often you see a tragedy in the ring, either a huge Subdural Hematoma (bleeding between the skull and brain), an Epidural Hematoma (bleeding between the tough outer membrane covering the brain and the skull), or a boxer collapses and dies and suffers a devastating neurological injury. And everyone seems to talk about it.   

What is far more hidden is probably the base of the iceberg. It’s the chronic neurological results of boxing which remain hidden because they don’t come to medical attention during the time the boxer is actively fighting. They present clinically after his or her career is over. People now talk about CTE (Chronic Traumatic Encephalopathy – a progressive degenerative disease of the brain found in people with a history of repetitive brain trauma) even though CTE is not a new disease.    

Apart from that the chronic post–traumatic headache, chronic post–traumatic cognitive problems, chronic post–traumatic dizziness, Parkinsonian-like syndromes; all of these things are what I say are the part of the iceberg that is hidden but which if you feel passionate about boxing, and about trying to make boxing safe, we should talk about.    

The issues that underpin this ‘iceberg’ analogy – can you expand on these? Are we talking about changing how a fight is conducted? Or monitoring fighters in the periods of time after sparring and training, and even after retirement?    

I actually mean you protect the brain health of a boxer. And the way you protect the brain health of a boxer is not just when he’s fighting. Yes, sure, you protect the brain health of a boxer when he’s actually fighting. Whether that involves better screening procedures, MRIs of the brain, EEG (a recording of brain activity), making sure fights are closely supervised. I devised a lot of protocols designed to make safe.    

Standardising medical stoppages in the ring. It’s unfortunate that after so many years there’s still no standardised medical stoppages in the ring. Some boxers are allowed to continue. A boxer is clearly concussed but allowed to continue but another boxer is stopped. So standardising medical stoppages in the ring. And it can be done.    

For example, I recently came out with an article where I tried to devise ‘No Go’ neurological criteria in boxing. And the idea was that if any of these neurological criteria were met during the course of a fight then the fight should be stopped on medical grounds. For example; a boxer goes down. It’s a knockdown. And he clearly has a loss of consciousness. It might be very momentary, it might be only a few seconds, but there’s a clear loss of consciousness. That fight should be stopped, no matter even if the boxer gets up, beats the count. That fight, in my opinion, is a medical stoppage on ‘No Go’ criteria.   

Another ‘No Go’ criteria – for example; a boxer is knocked down, he gets up but he’s clearly got what I call ‘gross motor instability’. He clearly doesn’t have his legs under him, he’s staggering around. He might have beaten the count but you and I both know he’s clearly concussed. And that’s why the fight should be stopped.   

So what I was saying was that one way you make boxing safer is by standardising medical stoppages, coming out with ‘No Go’ criteria, having good interaction between the referee and the ringside physician.   

I personally feel that every boxer should have an MRI at the start of his or her career that serves as a baseline. Let’s assume that the boxer will fight for about 10 years, he or she should undergo an MRI every three years. So once at the start of their career, one in the middle, and one at the end of their career. If in any one of these MRI scans a concern is raised, whether it’s evidence of traumatic brain injury, a small micro-bleed, some scar tissue here and there, then that fighter should be red flagged, have a more thorough examination, referred to a neurologist. Then on a case-by-case basis a decision is made on whether to continue with their career under close observation or hang up their gloves.     

The second thing would be something called a ‘neuro-cognitive examination’. You get this in the NFL. It’s a test to look at attention, concentration, memory, short-term memory, verbal memory. So you get baselines on these athletes. And let’s assume he gets concussed. That NFL player’s not allowed to return to the game until he meets the neuro-cognitive examination and he’s back at his baseline. So you can imagine this is one way to track the brain health of these elite athletes. If we see a boxer’s neuro-cognitive scores are declining over the years we might counsel him and say, “Listen, I think you should hang up your gloves.”    

So what I propose is the same thing. Do a formal neuro-cognitive evaluation at the baseline when he or she is applying for licence. Get the baseline cognitive function; attention, concentration, memory, short-term memory, verbal memory. And then repeat that every three years. Once in the middle, once towards the end of the career. And then you prognosticate.    

In terms of what’s neurologically more damaging for a boxer, are you able to say if a really tough 12-round fight is worse for the brain than a one punch knockout?   

That has also been debated a lot. You might say, ‘Is a slugger more at risk of getting Acute Traumatic or Chronic Traumatic Brain Injury versus a boxer?’ You know, the guys who just stand there in the pocket and trade punches.  

The danger of Acute Traumatic Brain Injury is always there. We all have witnessed some tragedies in the ring in the last few years. That too I am very passionate about. For example, I was giving a talk and I said: “You’re in New York, you’re walking across 6th Avenue and somebody assaults you. You go down, you’re knocked down, you dust yourself down and you say to yourself, ‘I’m gonna continue’.” You go up to 7th Avenue and at 7th Avenue you’re again assaulted, you again go down and you dust yourself off and you walk across to 8th Avenue and you’re again assaulted. At some point you’re not gonna be able to get up and dust yourself off.”  

For boxing to be made safer the culture needs to change. The boxing culture needs to change. The NFL culture has changed. The football culture has changed. The boxing culture needs to change. And that change in culture comes when people understand that the risk of acute TBI is there with every punch. 

How long should a fighter rest, sparring or fighting, after they’ve suffered a knockout?   

When you suffer a concussion or a KO the symptoms are all subjective. So what I call ‘post-concussion symptoms’ or ‘post-concussion syndrome’ the person will have a headache, called a post concussive headache, he or she will say, “I’m slightly dizzy or off balance”, they might feel after the concussion, “lights used to bother me, bright lights, loud sounds used to bother me, I’m feeling nauseated, foggy in the brain.”   

All these symptoms are subjective. There’s no way you or I can figure out whether he’s back to baseline or not. So that’s when things get even harder.    

Because boxers need to be honest. Their teams, their families, need to be honest. It’s a very strange sport. I have patients who come to me in the ER and they’ve suffered a concussion. They come into the emergency department and they’re very worried that they’ve suffered a head injury, they tell me all about how they fell off their scooter or whatever. Their family members are there, they want to have a CAT scan, they want to make sure the brain is healthy. Now contrast that with the ringside setting. You get up to ask the boxer, “Are you hurt? Is your head hurting?”   
“Oh, why are you even asking me that?! Why are you even stepping up to the canvas?!”   

The boxer will deny, deny, deny. His team, which I think of as his family, will deny, deny, deny. So how can a doctor make the sport safer? There’s so much riding on this. These are subjective complaints, so when you say whether someone should have a 45-day medical suspension or a 90-day suspension, or more or less, there’s no way you can prognose it. That’s where it becomes very hard.    

So you wouldn’t want to standardise a suspension in the same way you’d like to standardise a stoppage? That you should have ‘X’ amount of time off?  

No, I feel that’s a great point you make. It should be standardised. This is the amount of time. You need to take time off. All studies show that after a head injury you need a period of cognitive and physical rest for the brain to recover. There’s no doubt about that. All of the data on Traumatic Brain Injuries that has come from the battlefields of Iraq, Afghanistan, WWI, WWII, says the same thing. So you’re right, that’s an excellent point. You standardise that this is the time you need off, a medical suspension after a fight.   

Much has been made of the risks that weight cutting pose to a fighter’s brain health, specifically that they’re more likely to be badly hurt if they’re very dehydrated on the scales. I wondered what your thoughts are on this. 

If you look at the MMA, this weight cutting is such a big problem, trying to make these weights, at times really unreasonable weight cuts. They clearly come in really dehydrated. As I see it you cannot separate the brain from the body and the body from the brain. You have a fighter coming in dehydrated. Is their reaction time is off? There’s no scientific certainty, a few articles here and there, but if you were to put my back to the wall I’d say a dehydrated boxer is more likely to be concussed. There is some data to say that a dehydrated boxer is probably going to feel a concussion more.    

In boxing a tragedy isn’t going to occur because of a cardiovascular cause. These are young athletes. Their hearts are in pretty good condition. They can take that dehydration also. A tragedy in the ring is always going to occur because of a neurological cause, it’s always going to be the case.   

There’s always one immediate question whenever major changes are called for, or further research is suggested… Who pays for it? 
Who pays for the research? And, more importantly, the thing is that there is no centralised commission or medical agency that is tracking the brain health of these athletes. Someone fights in England, he or she gets an MRI of the brain before the fight, that same athlete fights in Kansas City and they don’t ask for any imaging. And nobody’s talking, the commissions aren’t talking to each other.  

So I also feel there should be a centralised medical, even if the sport’s different governing bodies should actually get together and form a central agency where the MRIs of these fighters are tracked. Everybody has access to them, where their cognitive score is tracked. Just like you have Box Rec you should have data driven research. That’s how you’re going to generate the data, that’s how you’re going to make the sport safe, that’s how you’re going to protect these athletes.    

Danny Williams
Danny Williams is a worrying example of a boxer being licensed in different territories

Danny Williams still very recently acquired a licence to box in Eastern Europe despite having shown worrying signs of cognitive damage for many years now…   

You are aware of the fight we had between Magomed (Abdusalamov) and Mike Perez in 2013. A heavyweight fight goes the distance. As I was told, Magomed didn’t appear to be experiencing any acute sort of problems during the fight. The fight gets done. He clears the post-fight protocols, steps out of Madison Square Garden between 12.30 and 1am and collapses. So that’s why I came up with, and we do it in New York now, it’s called the Red Flag Policy.

What it was, let’s assume we have a fighter. During the fight itself, let’s assume the fight goes the distance and during the course of the fight no concern is raised. Immediately post-fight the fighter looks stable. Now I have two options. Option One is I can just discharge him from the venue. Or Option Two is I can say “Listen, it was a tough fight. A lot of blows were exchanged. I want to observe you for about 15-20 minutes.” So we Red Flag these fighters.

He stays in the commission room for 15-20 minutes, he’s observed by a doctor, serial neurological examinations are done, and then a decision is made on whether he’s discharged home or whether he’s sent to the hospital if his condition changes. But this was my way of trying to prevent what happened with Magomed, a fighter who clears everything but then collapses.   

I can see that the pressure on you as a doctor at ringside must be immense.  

In New York either the referee or the ringside physician can stop the fight, so there’s a lot of responsibility on the ringside physician. As I see it the ringside physician should have the lowest threshold for stopping the fight. He’s there as a doctor and no doctor likes the brain or the athlete to get injured. He or she should have the lowest threshold. If they have a very high threshold they’re there as a fan. A referee will have a different threshold for stopping a fight. The referee is looking at the fight from a different angle. The boxer himself might have the highest threshold for stopping a fight, he might respond with “I’m fine, let the fight go on.”    

But what I’m trying to say is, I strongly believe that when tragedies occur in the ring and somebody dies it’s a systematic failure. It’s not just a failure of one doctor or one referee or the corner. Multiple people fail in their job and this tragedy occurs.   

Do you think it’s possible to standardise how a referee decides whether or not a fighter can continue? 

I believe that needs to be looked at too because in many countries only a referee can stop the fight. So I feel a referee should have a knowledge of concussions. It’s really important that a referee is highly knowledgeable about concussions. Like I already said, a referee and a doctor may have different thresholds for stopping a fight. A referee might say a fight can continue and a doctor might say “No, I’m stopping the fight.” That can happen, and when it happens and a doctor stops the fight, fine. A decision was made, a medical professional made a decision and he or she stopped the fight.    

Like, for example, in New York we have also standardised a little of how the referee assesses for concussion after a knockdown. So, for example, in New York he would allow the fighter to get up, he’ll ask the fighter to move towards him, he’ll watch the fighter walk in a straight line so he can do a quick heel-to-toe test. He might ask the fighter to step to one side, the left side or the right side to see if he staggers rather than just walk in a straight line, and he can make him do a two-step command. “Take your right hand, touch your left ear.” Is he there again? Is he there or is he all glazed up? And then you have to have the courage, the moral courage, to do the right thing when you feel you cannot guarantee the health and safety of the fighter.