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On average, two college students per year become the sacrificial offerings of higher education institutions that prioritize competitive success over safety.

Since 2000, at least 35 NCAA college football players have perished, and 29 of those occurred due to nontraumatic, and largely preventable, circumstances. The latest casualty is Jordan McNair, a sophomore at the University of Maryland at College Park who died from heatstroke while training for the 2018 season. McNair’s death -- and the resultant concerns about a “toxic” culture permeating the football program -- prompted Maryland’s president to commission a special investigation of the institution’s athletics culture, which was later taken over by the University System of Maryland’s Board of Regents.

The commission’s close to 200-page report, released days ago, described two years of “dysfunction,” unclear reporting lines and a lack of accountability and oversight at Maryland. The document verified accounts of abjectly dangerous and demeaning verbal and physical abuse -- largely under the guise of motivational tactics -- especially by Rick Court, a strength and conditioning official and the first hire of head football coach DJ Durkin, according to the report. Moreover, the report described “a culture where problems festered because too many players feared speaking out” -- the kind of environment in which a 19-year-old might not receive, or even request, proper medical care. Ultimately, McNair exhibited the textbook signs of heatstroke, and the institution failed to implement its own emergency measures.

Unfortunately, Maryland’s commission laundered their analysis of the facts, refusing to label the athletic department’s culture as toxic. The report declared that Court “did have the best interest of the players at heart,” a dubious conclusion given the totality of the evidence and the institution’s quick separation with him. It downplayed Durkin’s culpability, reasoning that he lacked the “tools, resources and guidance” to be a first-time Big 10 head coach. Such rationalizations obfuscate the severity of the mistakes, wrongly understate the institution’s ability to prevent injury and death, and undermine President Wallace Loh’s statement that Maryland “accepts legal and moral responsibility.”

McNair’s disastrous death -- and the shocking revelations that ensued -- are a symptom of an underlying disease. The root illness is the mind-set of some institutional leaders that the benefits of athletics success are worth the seemingly minimal risks to safety. Maryland is a case study on how that bet sometimes ends badly and a reminder that the rewards never justify the risk. Maryland is also a wake-up call to higher education leaders to get serious about making student safety our highest priority.

Three steps could help ensure that universities prioritize student athletes’ safety above all else.

Step 1: Every higher education leader needs to understand that the requisite medical protocols to prevent nontraumatic student athlete deaths already exist. Athletic training scholars indicate that careful planning, adopting evidence-based policies and ensuring the availability of required equipment nearly always prevent nontraumatic death. Exertional heat stroke, which killed McNair, is almost guaranteed to be survivable if handled professionally and expeditiously.

Colleges and universities must permit medical protocols to drive athletics-related policies, procedures and structures. They must regularly review and update those policies, procedures and structures and systematically test the institution’s implementation performance. The problem is that institutions adopt and implement medical treatment guidelines and organizational best practices to different degrees.

Step 2: Division I institutions should seek inspiration from Division III programs. Division I sports, especially football and basketball, glamorize and incentivize success through rankings, television, sponsorships and other enticements. The primary focus is on spectators, winning and money. In contrast, Division III programs “place special importance on the impact of athletics on the participants.” Division III coaches tend to become trusted confidants for their students. They often view their players as an extension of their families.

It is human nature to prevent bad things from happening to family members. Relatively few of the nontraumatic student athlete deaths since 2000 occurred in Division III programs. But that is not because they lack big-time pressure. A number of Division III institutions depend on student tuition and fees for upwards of 80 percent of their annual budgets. Athletics staffs can be responsible for recruiting more than half of an institution’s entire student body. A bad year for a prominent sports team could quickly lead to a budget crisis. Yet that pressure does not translate into reckless bets that endanger student athletes.

Division I athletic scholarships and the complex, loaded contractual relationships they create may cause some coaches and staffers to view student athletes as employees, an issue garnering legal attention in recent years. While Division I institutions cannot just cast aside these dynamics, their leaders should challenge themselves to look beyond their own flawed cultures and seek balance when making decisions impacting student athletes.

Step 3: Universities should hire administrators and coaches who understand that treating student athletes well is not just right -- it is also profitable. Corporate executives like Richard Branson of Virgin Group and Craig Jelinek of Costco have demonstrated that treating employees like family can produce happier, more productive organizations with healthy bottom lines. A study found that this lesson extends to coaching behaviors. Coaches directly affect a wide range of metrics, including retention levels, graduation rates and the future coaching styles of their students. Hiring people who understand the profitability of ethics, kindness and a family atmosphere in our institutions will reduce needless risk taking in the name of winning.

Undoubtedly, the University of Maryland profoundly regrets the risks they took and the culture that led to the death of a student athlete. Will your institution be next?

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