In many ways, the revelation that chronic neurological disorders were plaguing former players, and represented a potential crisis for the NFL, began in Baltimore with John Mackey.

Mackey was the first elected president of the National Football League Players Association after the AFL-NFL merger, and Sylvia Mackey picked up the advocacy ball in the wake of his diagnosis, exposing how little the NFL, with annual revenues estimated at $15 billion today, did to assist former players struggling with dementia. Publicly shamed, the league created what’s since been known as the “88 Plan”—an homage to Mackey’s jersey number—in 2007. Today, it provides up to $130,000 annually for nursing facility care and up to $118,000 annually for home custodial care for former NFL players with a diagnosis of dementia, ALS, or Parkinson’s Disease. At the same time, former Colts Bruce Laird, Jim Mutscheller, and Sam Havrilak, witnessing firsthand Mackey's deterioration and the hardship placed on his family, and frustrated by the lack of attention from the NFL, launched the Fourth & Goal Foundation to help retired players. Although the NFL agreed to increase assistance to retired players with the 88 Plan, it was still denying any link between football and CTE, dementia, and other brain diseases.

In fact, it took a more than a decade for the NFL to budge from their stance, even as Dr. Omalu and researchers at Boston University continued to document the widespread presence of CTE in deceased players. (The hallmark of the disease is an abnormal accumulation of defective tau proteins in the brain.) During this period, the high-profile suicides of relatively young former stars, including ex-Steeler Terry Long, who played alongside Mike Webster, former Philadelphia Eagle Andre Waters, ex-Chicago Bear Dave Duerson, ex-Atlanta Falcon Ray Easterling, and former San Diego Charger Junior Seau continued to stack up. All died by suicide between 2005 and 2012 and were later found to have CTE. It wasn’t until just three years ago, after Boston University identified the disease in 90 of the 94 former players it had studied, that the NFL’s top health and safety officer, under Congressional scrutiny, conceded football’s connection to devastating brain diseases. (Laird, Matte, and others accuse the NFL of taking a page from Big Tobacco’s playbook with its history of pushback and denial of legal responsibility.) Since then, the news for football players has only gotten worse.

According to the latest research from the National Institutes of Health, not only is the risk of dementia for former NFL players five times higher than the general population, the risk of developing ALS is four times higher. Ex-Raven O.J. Brigance, who was diagnosed with ALS 12 years ago, is hardly the only recent example. Ex-San Francisco 49er Dwight Clarke, who made perhaps the most famous catch in NFL history in the 1981 NFC Championship, battled ALS before his death last year. Studies show similar increased risks for Parkinson’s and Lewy Body Disease.

The most urgent news, however, pertains to kids: Participation in youth football is now also linked to a significantly greater likelihood of a CTE diagnosis after death. Of the 211 deceased former high school, college, and professional football players diagnosed with CTE in a 2018 Boston University study, those who had started participating in tackle football before age 12 displayed an earlier onset of cognitive, behavior, and mood impairment by an average of 13 years.

Since CTE is found almost exclusively in athletes who play contact sports, what does it mean for the future of football?

For starters, it’s already slicing into the profit margins of NFL team owners. More than $681 million in claims to date have been paid after the league chose to sign a broad settlement rather than litigate hundreds of separate lawsuits brought by former players, who were alleging the NFL had hidden what they knew about the link between repetitive head trauma and brain disease. As of last month, there have been 126 confirmed CTE cases, and a staggering 477 Alzheimer’s, 165 Parkinson’s, and 55 ALS diagnoses asserted by former players or their representatives. The vast majority of these claims have already been paid or are on their way to approval. Another 407 players have received compensation after other neurological impairment diagnoses, with still more cases in process.

Active NFL players are taking notice, too. A number of top players have begun leaving the game early. Among them are former Ravens linemen Eugene Monroe, who retired in 2016 at 29, and John Urschel, who retired in 2017 at 26. Both said their decision was led by brain trauma-related concerns. (Urschel, who is pursuing a PhD in math at MIT, made his announcement two days after the release of the study that found CTE in 110 of 111 former NFL players. He said an earlier concussion had hurt his ability to do high-level mathematics for several weeks.) Retired former Ravens tackle Michael Oher, 31, whose life story was chronicled in the film The Blind Side, and former Ravens star running back Jamal Lewis, 40, have each expressed fears they’re experiencing brain-injury related symptoms, with Lewis admitting he’s had suicidal thoughts since his career ended. “The last 18 years have been full of traumatic injuries to both my head and my body,” Monroe wrote in The Players’ Tribune, explaining his decision. “I’m not complaining, just stating a fact. Has the damage to my brain already been done? Do I have CTE? I hope I don’t, but over 90 percent of the brains of former NFL players that have been examined showed signs of the disease. I am terrified.”

Two weeks before the start of this season, former Ravens All-Pro fullback Le'Ron McClain issued an early Saturday morning plea for help on Twitter: “I have to get my head checked. Playing fullback since high school. It takes too [expletive] much to do anything. My brain is [expletive] tired. NFL, I need some help with this [expletive]. Dark times and it’s showing. [Expletive] help me please! They don’t care. I had to get lawyers, man!”

Hampering football’s long-term viability—its pipeline of young athletes—multiple states in the past two years, including Maryland, have introduced legislation to ban youth tackle football. That legislation has yet to go anywhere in Annapolis, but ultimately it may not matter. The number of boys playing tackle in the U.S. fell almost 20 percent between 2009 and 2015. American mothers and fathers clearly had begun recognizing the science before the NFL did.

“Howard County Recreation and Parks, among others, will tell you the numbers are dropping,” says Howard County state delegate Dr. Terri Hill, who drafted the youth tackle football ban in Maryland with the help of then University of Baltimore law student Madieu Williams, a former NFL safety. “I don’t think the conversation over CTE and youth football is over; I think it’s just starting. The U.S. Soccer Federation has already banned heading below age 12. As a society, we love football. I like football,” she continues. “But it’s not a binary choice between youth tackle football and the values instilled through team sports. There's touch and flag football and other sports.”

Femi Ayanbadejo, who played 10 years in NFL, earning a Super Bowl ring with the Ravens in 2000, said the possibility of brain injury wasn't a subject discussed in NFL locker rooms when he retired in 2007. “It is now,” says Ayanbadejo, whose brother also starred for the Ravens. He adds that while he believes the game is being made safer, with less tackling at practices, for example, he wouldn't let his own son play football until he turned 13 this year. “He's a very good athlete, but you should play other sports at a young age. I didn't play football until high school and then I only played two years.”