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Friday, July 31, 2009

A very different view on anti-doping

Q&A with Dr. Bengt Kayser on the doping dilemma in sport

Le Tour de France has now passed us by, although news from the cycling world is still coming thick and fast as rumours abound about who might and might not move to the new Team Radioshack in 2010. Also, the million dollar question is where will Alberto Contador ride in 2010? So many questions remain about Astana's future makeup---and Vinokourov's comeback---and Radioshack seems to have scooped many of the very good support riders from the current Astana. For some it might read like a soap opera on wheels, but that is part of the drama of cycling!

And we all know that drama is never far from cycling, even after the tour, because it was just announced that Mikael Astarloza, winner of Stage 16 into Bourg-Saint Maurice, tested positive for EPO on 26 June, just prior to the start of the tour. This follows on a positive test for Inigo Landaluze for CERA back in June during the Dauphine Libere stage race, announced during the Tour de France, which kind of flew under our radar. As an aside, there are very interesting Wikipedia pages listing all of the positive tests in sport, and also in cycling. Unfortunately, you have to check back often for updates!

But just when it seemed that cycling was getting things under control we see that the positives still persist and are very much still part of the scenery. Thankfully Landaluze admitted outright to his doping and saved us from any kind of protracted legal battle about lab procedures and test results.

Interestingly, the same day we received this news about Astarloza, we also received answer to a Q & A from Dr. Bengt Kayser, a medical doctor and also a Ph.D. and well published sports scientist from the Faculty of Medicine at the University of Geneva in Switzerland. Back in early June I attended the American College of Sports Medicine annual meeting, and Bengt was one speaker in a symposium titled, "Anti-doping efforts: Is it worth it?" Bengt presented across from Tom Murray, president and CEO of The Hastings Institute in New York.

The symposium was not really a "for/against" debate, but both Tom and Bengt presented thorough and compelling arguments to strive to a 100% clean sport (Tom) and to consider some alternatives to the current situation (Bengt). To sum up, Bengt's main position is that attempts to prohibit doping are doomed to failure, and therefore the only pragmatic response we should be striving for is regulation or control, not prohibition. Bengt has kindly rewarded us with the answers to a few questions, which come to us just as this most recent positive test was announced.

So, is it worth it?

The primary message I took away from this symposium is that even as much as I think about doping in sport and consider myself a very well-informed fan due to my sports science background, there are many valid questions and challenges to the current situation. Mostly, these are important arguments that apply more to our society but are nevertheless important to how we frame and approach the problem of doping in sport. The problem---not how much doping, but rather the fact that it exists---is much bigger than you think when one stops and places it in the much bigger picture of life. Sport is not isolated in a little box outside of our cultures and societies, and as such the larger cultural and societal forces influence sporting culture and sporting "society." But enough social science already. . .On with the Q&A!

Sports Scientists:
What are the primary reasons to permit controlled use of performance-enhancing substances?

Bengt Kayser:

1) Public health aspect: because doping and doping-like practices are forced into hiding, especially outside elite sport, there is increased prevalence of dangerous behavior including sharing of syringes and the use of products of uncertain origin. The best example is anabolic steroid use for body building. Repression will not work, certainly not in a democratic society; therefore evidence-based controlled use and harm reduction must be discussed as potential alternatives for more pragmatic solutions. This is already partly being done for steroid users in the UK and Australia, with some success since more syringes are being exchanged for steroid injection than for heroin in the UK. [SS: Very interesting fact, that speaks to the larger societal issues at work in this debate.]

2) Anti-doping cannot be successful. There are limits to testing technology and in order to prevent false accusations from laboratory uncertainty (sensitivity and sensibility) the cut-off levels anti-doping uses have to remain on the safe side leaving considerable space for well-accomplished athletes to stay under the radar.

This is problematic since the aim of anti-doping is to be 100% certain that the winners are clean, but there is no way to tell that with certainty. Remember that Rasmussen and Jones never tested positive despite numerous tests. [And let's not forget Bernard Kohl, who alleges that he doped for a long time before finally testing positve--SS] Today a champion is unfortunately a suspect by definition. The discussions in the press and on the web of the 2009 Tour and other championships show this perpetual suspicion clearly.

3) The trend of anti-doping is towards serious intrusion into the private sphere of the athlete. Reporting one’s whereabouts 365 days a year is quite something. There is even talk of carrying a GPS to be tracked at all-time. Genetic profiling is being used for forensic use. This all points towards a potentially dangerous slippery slope towards wide-spread controls in society at large. I find the prospect of a totalitarian system of ubiquitous control rather disconcerting. Are we going towards urine control in students before an exam? Blood passports in kids who exhibit talent in a given sport?

Do you feel athletes should be able to take any drug in therapeutic doses so long as the doctors disclose the information? If so, what will this accomplish?

I presume you mean therapeutic in the sense not to treat a disease but in doses that come with acceptable risk. [Correct---SS] Yes, that is a potential way to go about it. Disclose and observe. It would lead to transparency and potential for evidence-based advice. It is very likely that the majority of the drugs on the WADA list do not have performance improving effects. If this can be proved the use of such products may become less popular.

Was there a time when you bought into the current model of doping control? Or was there perhaps a time when your views were more "innocent" towards doping in sport?

Before the introduction of the present coercive system I thought that the system was more or less well self-regulating. But I never believed in the current model, certainly not when I discovered the whereabouts rule and other intrusions in the private sphere of the elite athlete. But in principle, as long as the ‘no-doping’ rule is in effect I find that one should not dope. This is cheating, which is presumably not right. I find that one should, again in principle, obey to the prevailing rule, but one may question the rule finding it in part ineffective, potentially dangerous, and not anchored in sufficiently solid reasoning to accept its side effects. Rules can change and do change when it is found that they do not work as well as hoped.

I predict that the anti-doping rule will change, probably not in the next 10 years, but thereafter. Think about how the world will look like 50 years from now---not many more world records to beat since we will have reached the limit of human performance (one cannot run the 100m in zero seconds and therefore the improvement of the record will become less and less). And a prospect of a performance enhanced society, where most citizens use technology to enhance, whereas the modern gladiators still stick to ‘natural means’ while competing, looks rather unrealistic to me.

SS: When did you first realize that we needed a different approach to anti-doping, or when did your paradigm shift?

I first realized what was happening when I attended a symposium at an international sports federation and heard anti-doping officials, including physicians, talk about their work and the anti-doping rules. It was truly an eye-opening experience, I was shocked. I thought we had escaped from Big Brother, but there he was. Also the way with which the anti-doping officials talked about athletes who were potentially doping was rather chilling. It all came with a strong flavor of ‘the end justifies the means’, even if this would imply sacrifice from (of) athletes.

SS: Do you feel the new biological passport is the answer to sports doping problems? What are its pros/cons, why will it or why won't it work?

Again, it can never be 100%. Of course, many doping practices will become extremely difficult or impossible, but many others continue, at low levels, or undiscovered since not included in the panel of measurements.

The accusation of innocent athletes (false positives are certain to occur the more we test) is something very uncomfortable to me; the sacrifice of innocents on the altar of what is known as ‘the spirit of sport’ is in my view difficult to accept. There is also the strict liability rule that is causing quite some harm, when athletes, clearly not because of willingly doping, find themselves accused and punished with potential devastating consequences on their private and professional lives.

SS: What can you say to the sports fans who still believe that the current controls are working?

Open your ears and eyes and think.

So there you have it, thanks very much to Bengt for taking the time out from his busy academic schedule to answer these questions, because part of our Vision and Mission is to translate the science that surrounds our sports, but also to provide the extra insight, analysis, and viewpoints that one cannot find anywhere else.

Admittedly this is a concise piece considering that one can write an entire thesis and then some on this topic. Fortunately, Bengt has published about this topic recently:

"Viewpoint: Legalisation of performance-enhancing drugs." The Lancet, v 366, 2005.
"Current anti-doping policy: a critical appraisal." BMC Medical Ethics, March 2007.
"Globlisation of anti-doping: the reverse side of the medal." British Medical Journal, July 2008.

as well as some other comments and letters in many journals. It might seem like a radical viewpoint, but the problem is that currently we are not winning the "war" against the cheaters, and so it is important to ask hard questions and think about things differently. One can only hope that the result, although perhaps radical at first, is something better in the long term.

Join us for more debate on the FINA Swimsuit debacle (talk about drama!) as the swimming world champs from Rome wrap up shortly, and then don't forget that the IAAF World Champs start on 15 August.



David Barry said...

I don't see how disclosure is going to work for a "controlled use" regime. Surely athletes who want an extra edge are just going to take whatever substances they can and not disclose anything that goes above the "controlled" amount allowed.

Anonymous said...

He could ask the clean athletes how they rate the risk of a false-pos vs the day-to-day experience of lining up against people they (with good reason) suspect are not playing fair.

He could ask the "dirty" athletes how many of them would have stayed clean if they'd had the confidence that most of their competitors were too.

To an extent I can see where he's coming from, but he doesn't sound like he's ever toed a line himself....

Ross Tucker and Jonathan Dugas said...

Hi Dave, thanks for your comment here. That is one of the assumptions/limitations about allowing use in therapeutic doses.

One assumes that the medical doctor administers the correct dose, but of course what is keeping the athlete from taking more on the side?

But then again, the current system assumes that the risk of getting caught and banned for two-years is a deterrent. Notice I said, "the current system," and not us, because I think informed fans of of at least cycling realize that this is not really a deterrent at all.

This was admittedly a short list of questions and answers about a topic that can have an entire website dedicated to it, but the point is to think about alternative approaches because the current arrangement has its own problems.

Hopefully Bengt can find the time to read these comments and engage them!

Kind Regards,

Unknown said...
This comment has been removed by the author.
Diarmuid said...

I can understand his approach but doesn't it fall at the same hurdle as the current approach?

Currently, say, zero amount of PED are allowed. In the proposed models, say x (a safe) amount of PED are allowed. However what if 2x produces an even greater performance improvement (but maybe unsafe). Now we are back to a battle of finding the cheaters (the 2x guys) from the rest?

Anonymous said...

I totally disagree with Bengt Kayser. Most things in life are about rules, and not beeing able to control the respectation of these rules under every possible condition is no reason to just abolish them! No one can control speeding on the Highway and still nobody is questioning speed traps, speed limits and the role of traffic police.
Furthermore, I read that we are LOOSING the fight against doping! NO !! We are fighting and winning some battles! Some examples: Anabolic steroids? Usage in high performance sports dropped dramatically since the introduction of out of competition testing. Stimulants? Virtually non existant at top level anymore. EPO? Much better situation since EPO Urine test and blood tests. Future drugs? Aranesp and Cera tests were ready before the substances were on the market and before the athletes knew..
Sure, nothing is perfect, but things get better!
And just remember: Sports is, by definition, fair play and based on each individual skills. And following Bengt Kaysers proposals would be against the very principles of sports.
No thanks !

djconnel said...

Virtually no rule in sports is perfectly enforced. Yet we persist in having rules. Anti-drug rules are no different. Shifting a threshold for what constitutes cheating won't change the fact that people will push the boundaries.

The Sports Scientists said...

Hi Anonymous,

One of the points of this exercise was to illustrate how perhaps the doping problem is grossly oversimplified. One problem now is that since the use of any substances is so strictly verboten, it all goes underground and there is no way to measure these things you talk about. Therefore there is no way to measure the (in)effectiveness of many of the substances on the banned list, because any disclosure by an athlete will immediately mean dismissal from their sport.

I know Bengt only so well, but like many a sport scientist I suspect he has toed the line before in different sports. At the very least he was an astronaut for the European Space Agency in the early 1990s, but anyway there was an article in Nature in 2007 called "Professor's little helper about academics who take things like modafanil and other CNS stimulants, and that is the other side of this argument---that we rail the athletes while white collar workers use performance-enhancing drugs of their own without any sanctions.

It should also be noted that the use of Ritalin on college and high school campuses is a growing problem, and that is the larger context of doping in sport. Where is the line drawn? Is it ok for healthy academics to use drugs to improve their academic performance? Before you answer, think about a scientist applying for a grant. It is a very competitive process, and one might be at an advantage if one can spend an extra amount of time preparing that grant for submission. It should be easy to see the similarity between this and athletes in a race.

My opinion is that doping should not be allowed in sport, but we have to examine the argument in a much larger context of society and life. How can we tolerate it in academics or the corporate world but scoff at athletes when they use it? That is a valid question, but one I am not sure I know the answer to!

Anyone who would like a copy of the Nature article, just email us and I can send it to you. It asks some interesting questions about this topic.

Kind Regards,

The Track & Field Superfan said...

Any time it is suggested that doping should be allowed and controlled, my response is to ask "in what way would that be easier to police than what we have now?" I don't think it would be at all.

It's a false dilemma to think that if we can't eliminate doping then we shouldn't try at all. Police don't take this approach with crime; it will always be there, yet we don't stop trying to keep it to a minimum.

Look at the level of marks in athletics if you think there's no movement on doping. Events where steroids were important are well behind what they did 20 years ago, and distance events are different now than 5 to 10 years ago. Once HGH is better controlled, sprints will slow down as well.

Tom R said...

I think comparing doping in athletics to doping in the rest of the world isn't fair. Athletics represent a game. There are set rules for the game. You start at the starting line, and finish at the finsh line. You have to use bipedal motion to get there. Or you have to kick a ball into the net without the use of your hands. Or a ball is pitched towards a batter. If it crosses over the plate in front of the batter without the batter hitting it, the pitch counts as a strike against the batter. The batter may not use a substance to enhance his/her performance in hitting the ball with a bat. The pitcher may not use a substance to aid in making the ball travel faster. The runner may not use a substance which makes him run faster. The game or race is defined by a set of rules, and not using a certain substance during/before/after the game is part of the rules. The rest of the world is a free-for-all. There are no rules in how to play, only laws which attempt to keep people from being able to harm themselves or others. I see doping more like an out-of-bounds line in a soccer match than a legislative action by a government.

Neil Hart said...

Two Comments: In reponse to Tom R's comments, I don't think it is necessarily fair to suggests that as proffessionals, atheletes and that much different to proffessors of business men. Yes sport has clear cut rules, and the "big world" not so much. Point is sports people live in the big world, if something is culturally accepted in day to day life, eg. professors little helpers, it easy to take that into their sport. Sport, which is a game to us as fans, is an athlete's full-time job!

Second comment: To add complication to the debate. I find that Kayser's position although well-informed and thought out, doesn't give any regard to athletes who want to succeed as clean players in their sport. And legalising doping albeit controlled, could likely end the aspirations of athletes who wish to compete based purely on physiology, clever training and just pure hard work.

Although and amateur athlete, one of the main reasons I do sport is for the challenge of training harder and more intelligently to ultimately see what my body is capable of and then, compete to see if I am stronger than those I ride or run against. Maybe there are not many professional athletes that think this way, but if there are, their side (in my reading) is not being consider that often. If I were to pursue a proffesional career in sport, I would quickly become disillusioned at the inability I had to compete with "controlled doped" colleagues who I knew didn't work as hard as I did to compete and still were superior on the road.

Farhad N Kapadia said...

Dear Jonathan & Ross,

Wonderful site. I hope to be a regular participant in future. Regarding the question of doping in sport. I’ve always felt that the assumption of a level playing field is excessively naive & doping is just one more aspect which gives some an advantage over others. What are your views of the recent development in India where the national cricketers have essentially refused the WADA clause which requires information as where they will be 365 days a year.


Thom said...

Clearly the standard needs to be, and I think this is the crux of Dr. Kayser's presentation, "Anti-doping controls should not do more harm than good," rather than, "Anything we can get away with that curtails doping is permissable," as it currently appears to be, even among fans.

24 hour electronic surveillance of athletes is the logical end of the current "whereabouts" system. "After all," the anti-doping bureaucrat might say, "just because we know where the athletes say they are (and we know better than to actually believe them), how do we know what they're up to?" The rest of us would, no doubt, be reassured that there will be many safeguards put in place to protect the privacy of the athletes -- as if they had any left!

I agree with Dr. Kayser; The current system does more harm than good to sport and to society in general. It's time WADA was put in it's proper place (the back shelf somewhere).

djconnel said...

I completely agree with Tom R's comments. Let's not confuse games with other endeavors in life. I certainly don't and haven't taken drugs more serious than light caffeine for my professional achievement, and don't in any way feel that's held me back. Sports is a matter where every second is measured and recorded.

Doping rules, like most universal sports rules, are all about removing the stimulus for hurting ourselves or each other. Like equipment rules for safety, we should keep that in mind: let the best one win without pushing the threshold of risk too far.

Then we can address the issue of drug use in society, and what it (legal or illegal) is doing to our collective health and economy, separately.

Ross Tucker and Jonathan Dugas said...

Hi Everyone, thanks for some great comments and observations here so far.

Just to respond to Thom for now, indeed, no one is saying that it should be a free-for-all for any athlete to take anything, but rather that the current approach has valid problems.

In many ways this is a personal choice, with some of us drawing a clear line between life and sport, while others feel that the situations are similar and it might be hypocritical to disallow athletes to take drugs while allowing it in other professional situations. The debate will continue about where exactly to draw that line and what is "in bounds" vs. "out of bounds."

People will always push the boundaries, but one reason to allow the use of these things is to at least finally measure their effect, because the banned list of substances is massive, with most of the listed substances probably producing little effect on performance. If we can narrow this list then it might be easier in the long run to test athletes.

I think an important point moving forward is that this is very much a moving target, and not just a simple black and white issue. the question of do allow or disallow is black and white---but then enforcing the rules and accomplishing the goal becomes tricky because on our current path we are moving towards 24 h monitoring of athletes, which as someone else pointed out here does not really accomplish that much because although we might know where you are we still do not know what you are doing.

I do agree that drugs should not be allowed, but currently there are problems with the anti-doping movement, and we must think more broadly and creatively about how to solve these problems down the line. Just realizing that there is a debate about where to draw the line between sport and life is only a beginning, and the really hard questions follow.

But thanks again to everyone, this warrants more discussion and also more posting. We hope to have more experts weigh in here on the site on this issue.

Kind Regards,

Anonymous said...

I won't argue with Dr. Kayser that doping controls aren't and may never be 100% effective, but that does not warrant completely throwing them out of the picture and opening our arms to controlled doping. If you allow doping, then you are potentially creating a similar problem that swimming is facing; the sport no longer becomes a test of natural ability, but one of technology.
The UCI has shown that more frequent and targeted testing improve the odds of snagging cheats (unfortunately it seems money, a good lawyer, and a public PR campaign go a long way in keeping a positive result controversial). Testing can continue to be a deterrent as long as a relatively high level of effectiveness is demonstrated.
But how about testing coupled with the influence of peers, fans, and sponsors? In cycling, more sponsors, teams, and riders are really being vocal about doping, and I think that is a reflection of a stronger public opinion that doping is cheating, and that cheating is wrong. I believe that will go a long way in influencing would-be cheaters.
Maybe sports federations should find creative ways to bring public opinion to athletes. Perhaps making them more aware of the public disdain for doping will strengthen the anti-doping movement from within…

pelotonjim said...

I may be tilting at windmills or run the risk of being called naive but here it goes. I don't think the reason for some level of legalization should be "Because we can't win."
I agree that you will never get to 100% certainty but you can continue the fight against cheating and achieve significant results. I will refrain from using the term 'winning' since this requires a preconceived notion as to what 'winning' means.
We should not focus on testing as being the only option. We need to move further upstream. I believe two key things about human nature. First, most people are generally good. Also, most people will take the easier path if given the choice. So we need to make the doping path less appealing than the clean path.
Cycling seems to be building a cleaner culture with the newer generation of cyclists. That is a good step. Harsh penalties will change the risk-reward profile as well. Options such as team/director penalties especially if there is any tolerance, either overt or turning a blind eye to activities, are also possibilities along the path.
I’m OK with the biological passport and the whereabouts notification. I don’t think that puts society as a whole on a slippery slope. I do think we need to guard against sacrificing innocents for the greater good. This is unacceptable.
So to sum, think about setting up hurdles along the whole doping path, not just a net at the end. Put up enough hurdles and most people will be redirected down the alternative path. This will leave a few sports sociopaths for you to catch at the end.

The Cycling Addiction said...

"So to sum, think about setting up hurdles along the whole doping path, not just a net at the end. Put up enough hurdles and most people will be redirected down the alternative path. This will leave a few sports sociopaths for you to catch at the end." pelotonjim

I think the comments made by pelotonjim are valid points to consider.

I have used my testimony as a former user and dealer to plants seeds of consideration to those in my local area or on the internet like on forums that have consider going down the wrong path.

I have told them what I went through and for some I am not sure I was able to break through but at least my story has stopped some long enough to consider things that can happen beyond just getting kicked out of competition. My testimony is also in an e-magazine so I have tried to reach out and use my experiences to help others and say, "don't go down this path."

I could spend a lot of time typing and still would not be able to cover it all so I am not going to attempt it.

It is a complex subject, but the complexity is dealing with a person's convictions.

Anonymous said...

Was One Won One said,
Get rid of the band substance list let racers race. If people are worried about the 'health' of the racers then set up physiological parameters such as the 50% crit levels and if they are over then they have to set out two weeks and retest to prove they are back at safe levels. This would stop all the hypocrisy and the Doctors could keep the racers performing at there best and recovering to the maximum levels they can achieve.

Unknown said...

Although this is simplistic, isn't INSULIN considered to be performance enhancing? No? Let's say you are a diabetic, and without it, you could never be competitive. So you take insulin, a prescribed med, and your performance is enhanced. Same with eyeglasses or contacts. Without them you can't see well enough to play ball, but with them, your performace is enhanced, and you can play.

On another note, I was very impressed with one of the German teams from either TdF 07 or 08 that pulled their team when one of their athletes tested positive. I thought that it was a great, firm stance, and a show of "all for one, and one for all" that idealizes TEAM.

Keep up the great work here. Very enjoyable and informative.


Dr Zen said...

I tend to agree with Gene. I've never been all that clear on the difference between hiring a dietician and hiring a chemist. The playing field is not level for all sorts of reasons, and we seem to have singled out drugs as the "bad" way to gain an advantage. But diet, access to quality coaching, equipment, the athlete's social setting, these all confer advantages and disadvantages. I can't think of many world-class African cyclists, for instance, but shouldn't there be some if everything were equal?