The British foundation behind research into rugby's cumulative impacts on the brain says the elite game is unsafe, and in an ominous warning accuses World Rugby of marking its own homework.
The Drake Foundation, which funded a study conducted by the Imperial College London that found half of elite adult rugby players showed a reduction in brain volume and almost a quarter displayed abnormalities in brain structure, believes World Rugby has not done enough in tackling head impacts.
"The elite game is not safe at the moment and that disturbs me," Drake Foundation founder James Drake told the Herald this week. "I don't have any reservations in saying that. The body of information across contact sport is a worrying picture. There is a problem here."
Drake has been on a crusade since establishing the foundation in 2014, investing more than $4 million into the long and short term effects of contact sport's impacts on brain heath.
The results of the latest study in July, published in the journal Brain Communications, found concerning links between elite rugby and changes in brain structure.
The study involved 44 rugby players - from seven unnamed professional union and league clubs in the UK - who had suffered mild injuries. It found 23 per cent of participants experienced changes to their brain structure in the neuronal white matter and blood vessels of the brain, while 50 per cent showed a reduction in brain volume.
The average age of participants was 25.
Drake draws comparisons to the initial outcry in the UK surrounding the risk of suffering a stroke from the Covid-19 astrazeneca vaccination – a risk placed at one in 10,000.
"The risk here of getting white matter change in elite rugby, from our small cohort, is almost one in four," Drake said. "Even though we don't know if these changes progress to clinical symptoms, it's not good. Who wants changes in their white matter in their 20s? I would suggest that any structural changes in any organ in your body is not a good thing."
World Rugby reacted to the study by adopting independent concussion consultants to support the graduated return to play process in the elite game, and last month issuing guidelines around reducing contact in training.
These includes limiting full contact to 15 minutes per week; 40 minutes of controlled contact utilising tackle shields and pads, and 30 minutes of live set piece training with lineouts, scrums and mauls at a high intensity.
The recommendations could soon be mandated, with test teams potentially obliged to follow guidelines in order to compete at the 2023 World Cup.
The changes in contact training come as former World Cup-winning England and Lions hooker Steve Thompson and a group of retired players continue to pursue their landmark legal case against World Rugby, the Rugby Football Union and Welsh Rugby Union after being diagnosed with early-onset dementia.
Thompson claims he has no memories from the 2003 World Cup in Australia, and often forgets his wife's name. He also suffers from anxiety and panic attacks.
Drake says World Rugby's latest training contact guidelines do not tackle the immediacy of the issue.
"World Rugby have now come forward to recommend the reduction in contract in training. That's not good enough. You don't recommend, you must enforce.
"Common sense will tell anyone that if you want to get down from 23 per cent to nill how on earth are you going to do that by just making changes in training. It's not going to happen, especially if you only recommend them.
"The problem with something like this is it's creeping forward. By the next World Cup it's got worse. I feel sad that players, a small minority, are experiencing early dementia in their 40s. That shocks me. That's lifelong. Their family, friends, everyone around them is affected for the rest of their lives."
One avenue Drake implores World Rugby to explore is significantly reducing replacements. He believes the ability to continually roll on big, fresh men and women only serves to enhance the toll of brain impacts.
"I can't see any reason why you can't forget substitutes except for injuries and fatigue.
"Don't have eight 20 stone [127kg] people coming on at 60 minutes. Why would you do that when you know there's a problem of this magnitude. That's crazy.
"Eight is far too many. You can't leave this for another eight years because it will get much worse.
"You've got to find ways to reduce the sub-concussive and concussive cumulative intensity of impacts. The problem cannot go away until it's properly addressed by World Rugby.
"If they'd incrementally decreased the impacts by having two, three subtitutes, having very little contact in training, then they'd have the data to show there are less problems. Instead they've let it carry on.
"The reason we're in this pickle is not enough has been done in the preceding decade."
The fabric of rugby union, and league, centres on collisions. To find ways to reduce those impacts Drake believes experts with no vested interests must be embraced, pointing to other examples these are used such as the Saracens salary cap scandal.
To this point he says rugby is guilty of "marking its own homework".
"You have to get an independent medical person to preside over this and ask is this reasonable?
"We don't have all the data but if you leave it until you find there are clinical symptoms it's far too late because you'll have thousands of people suffering.
"If there is a slow increase in the number of these cases, and if one waits for the scientific evidence way down the line to prove symptoms, it's going to be horrendous. I worry about what the long-term implications will be for rugby union. You have to make a common sense judgement. This is a watershed moment.
"My heart goes out to any player suffering from brain problems in their 40s when they can live for many years longer.
"The publication of the brain study should illuminate the real issues here. Players and administrators need to get together and say 'let's look at the impacts, the impact sensor data and work out how we can reduce it'.
"You have to make a significant changes – not just throw in the 50/22 rule and these sorts of things. It's not enough. If 23 per cent of players have these changes it's not going to go down without a significant reduction.
"As always when you put a problem on the shelf it gets much worse."
Drake says his intent is not to scaremonger but push for the elite game to be safer. He remains a strong proponent of the benefits of adolescent involvement in sport, including the rugby codes, but says the elite game has changed beyond recognition since the turn of professionalism in 1995, with all players now bigger and more powerful which increases the ramifications of cumulative impacts.
"World Rugby are not doing the grassroots players any favours whatsoever by not cracking down on this and making it clear they're going to reduce it. I find it disturbing they're not doing more."