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Doping Journal 4, 1 (8 August 2007)
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Anthony P Millar
Anthony P. Millar, MB, FRACP, FACRM,
Director for Research, Lewisham Sports Medicine Institute, 1 West St, Petersham NSW 2049, Australia
email: firstname.lastname@example.org, email@example.com
Submitted: 19 April 2007 | Published online: 8 August, 2007 | Article readership
Copyright © 2007 by Anthony P Millar, licensee The Doping Journal
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Drug testing was introduced at the Grenoble Winter Games in 1968 and
since then it has been pursued under a "law and order" approach. As
there are still positives being found, it is obvious that drug use has
not been eliminated. Information about the number of tests performed
and the frequency of positives is not readily available from all
sporting bodies and, even if they were accessible, previous experience
would make one wary of accepting them. There are no independent
examiners to allay any doubts. As drug testing is expensive and
penalties are not uniform, it is time, as has previously been suggested [
1 ], that the whole program was reassessed. Under the present system
athletes bear the total punishment and personal denigration but similar
treatment must also be handed out to the judges in competitions who
2 ] to officials of associations who sweep positives under the
table and members of medical commissions who connive to free positive
testing athletes [
3 ]. Those who manage the athletes and help them to
contravene the rules also deserve to share the same punishment as the
athlete. This includes the trainers, physicians, coaches and others who
promulgate the values of drug taking and encourage athletes to break
Drugs have been used from pre-Christian times and even in mythology, performers used unfair tactics. In the Iliad, Homer described how Odysseus implored Athena to trip Ajax, showing that even the Greeks of the old world were aware of cheating. Voy [ 4 ] recorded the use of brandy and wine concoctions with mushrooms to help performance. Stimulant use has continued down the years and has led to the development of new preparations and new uses for older pharmaceuticals. Recent revelations about the development of THG [ 5 ] and other designer drugs in the Balco laboratories testify to the fact that the search for the perfect performance booster has not been abandoned.
The definition of a drug is difficult. It has been stated [ 6 ] that the US Food and Drug administration defined a drug as "any substance that is not a food" and further clarified the position by defining a food as "any substance that is not a drug"! Such tautology does nothing to remove confusion. The World Anti-Doping Agency totally ignores the problem. The International Olympic Committee overcomes the problem by equating drug use with doping which it defines as: "The use by any competitor of any substance foreign to the human body, or any physiological substance taken in an abnormal quantity or by an abnormal route with the sole purpose of increasing in an unfair manner his/her performance in competition. When necessity demands medical treatment with any substance, which because of it nature, dosage or application is able to boost the athlete's performance in competition in an artificial and unfair manner, this too is doping".
This definition completely ignores development of mechanical aids in sport. There are bicycles with advantages over others giving an unfair edge to the owners. Swimming costumes which decrease drag through the water are a disadvantage to those who do not have access to them. When Seagram introduced the fibreglass pole for the pole vault, it was banned until it was universally available. Why does this approach not apply today? A physiological substance used in abnormal amounts is Creatine Phosphate. This, by definition, is doping but the testing authority, the World Anti-Doping Agency, allows it. The ambivalence and inconsistency in this decision adds to the confusion about classifying substances. Substances used for therapeutic purposes are banned. This does not apply to laser therapy to improve vision or surgery to improve knee function after an injury. These therapies are designed to improve the athlete's performance and yet are accepted by authorities. A similar state arises with the use of altitude tents to increase EPO levels. This represents the use of hypoxia to improve performance in an unfair manner. Where does one draw the line in therapy? Why should athletes with illnesses that can be treated by pharmacological means be penalised? Under the IOC definition, any therapeutic substance would be banned. That will include water used for dehydration in the marathon runners for example. The absurdity of this definition is obvious. Diabetics are allowed to use insulin, a banned substance and no-one could complain about that. What is there to stop a diabetic cheating by adding 20 units or so to gain the advantage that insulin is supposed to give? If diabetics are treated in a way that breaks the WADA rules, why can hypertensives not take beta-blockers which have controlled their blood- pressure instead of changing to another antihypertensive which does not suit them as well? There is no penalty applied to athletes who have a surgical procedure which will improve their performance. Athletes who have a medical problem are unfairly treated as they cannot follow the best therapeutic path for their illness. There is much confusion here. The authorities want to punish everyone to ensure that the guilty do not escape. Just imagine if murder investigations were carried on like this! This is a third world - or worse- approach to justice!
With all the furore about drug use after the Ben Johnson saga in the Seoul Olympic Games there was a need for some response and an enquiry was set up. In his report the commissioner [ 7 ] noted that "they (the Olympic Games) unite Olympic competitors of all countries in fair and equal competition." This thesis has never been tested and a casual glance at the teams present shows the differences that make the Games totally unequal and unfair
The reasons for banning the use of Performance Enhancing Substances (PES) fall into two main areas. The use of the substance is unfair and, when that fails, there is a danger to the athlete that needs to be considered. These two categories encompass the arguments of opponents of the use of PES and need to be addressed if there is to be a system that is equitable to everyone. A further argument is that sponsors will be deterred if drugs are used in high level sport and that governments will act adversely and withdraw support. There is nothing to support this thesis. Fans come to see Herculean efforts and the fact that competitors may have used drugs has not deterred record attendances. The fans want to be entertained and the popularly held belief that all athletes take drugs has not deterred attendees.
The concept of fairness suggests all are equal. The obvious genetic
variations between participants show how unfair the system can be. A
consideration of the variation in height in competitors in the high
jump shows the impossibility of a man 160 cms winning the high jump.
This is accepted as innate but it is still unfair to the short athlete.
In boxing, weight categories lessen the differences and are fairer to
the lighter boxer. This could be done in athletics but there is no
interest on the part of organisers to level the playing field to
diminish the stress of unfairness. Social factors intrude into
training. Some athletes are supported by the state or a foundation
giving them an advantage over the competitor who has to work to supply
family needs and is thus restricted in the time available to train and
cannot afford overseas competition. There is an unequal availability of
Sports Medicine support between countries. Specialised equipment is
more accessible in affluent countries. These differences show that a
level playing field is an impossibility. Black, after an extensive
review, concluded that arguments to ban drugs on the ground of
unfairness are totally implausible [ 8 ]. It is incongruous that
drugs are the only item equally available to all sporting participants.
The fact that one athlete may not want to take them should not affect
another. If an athlete only wishes to train two days a week, this
should not restrict his opponents. He must be prepared to come last.
And a similar approach could apply to drugs.
When the appeal to fairness fails, the next target is the danger to
health from drug use. The main drugs attacked are the anabolic
steroids. They have been credited with causing heart disease [ 9 ] but
there has been no follow up of former users to confirm the excessive
occurrence of heart disease in users. Studies have shown there is no
difference in left ventricular measurements between users and non-users
[ 10 ]. More recent studies have shown that the changes in the
ventricular wall persist for an extended period in a gradually
diminishing way [ 11 ]. Later studies showed that the abnormality in left
ventricular hypertrophy decreased over the years suggesting that
eventually the changes may not be detectable. Changes in lipid profiles
have been reported [ 12 ] but the changes reverted to normal after the
course of steroids was completed. There is no evidence to support the
view that a reduction in HDL for 3 or even 6 months has any significant
effect on coronary artery disease. When one considers users do not
smoke, eat low fat diets and train regularly, all recommended actions
to minimise heart disease, there is a need for further investigation to
evaluate the long-term effects of steroids and any supposed link to
To further reduce the demand for steroids the threat of developing cancer has been associated with their use. This has been promulgated in spite of the fact that, as early as 1984 Haupt and Rovere [ 13 ] showed, most of these were in patients with haemopoietic disease and were on extended therapeutic courses. A review by Friedl [ 14 ] cast further doubt on the nature of the tumours. A report by Socas [ 15 ] and his group discussed two cases of liver tumour that regressed after the cessation of steroids. This fact and the failure of tumours to metastasise throws doubt upon the correct terminology for these tumours It is interesting to note that there is no outcry about the possible occurrence of carcinomata in women who use the contraceptive pill to enable them to perform at the optimal time in their menstrual cycle .There has been much written about the psychological and behavioural effects of the drugs. The subject has been well reviewed [ 16 ]. This review discusses the methodological problems associated with the evaluation not only of psychological effects but also all other areas connected with steroid use. This is a unique review highlighting the failures in addressing the problem areas of anabolic steroids. Research is prevented by "ethical" considerations - a strange state of affairs when the testing of new drugs is concerned where future effects are downplayed.
Human Growth Hormone is a newer addition to the pharmaceutical armoury and reports are less frequent about its adverse effects [ 17 ]. Most are based on the idea that any problem is likely to be a variation of acromegaly. There have been sporadic reports of skin changes and organ enlargement but little of a documented thesis which can be evaluated [ 18 ]. Erythropoietin has been shown to increase blood viscosity and this is deleterious to performance. Other substances used such as ephedrine and caffeine, have even worse documentation when their effects on performance is assessed. There is a great need for further research into such substances if advice is to be given to the athletes and their testers.
COMMERCE AND GOVERNMENT
It is difficult to believe that the TV firms who pay such exorbitant amounts of money to televise high level sport would be worried in private at least, that some or all athletes were using drugs. When one recalls the days of amateurs, as distinct from professionals, receiving money under the lap, [ 19 ] journalistic sources still reported events and the monetary rewards were considered as a just reward in spite of recriminations that sponsorship and government approval will be lost. The "crime" did not affect any programs and now all athletes are in one category and monetary gains are part of daily sport. Similarly governments accepted the state of affairs as to do otherwise would lose votes. Fans come to the events to see record breaking performances that often result from the use of drugs. The fans want to see new world records and they want to be entertained. It is common to hear today that all athletes are on drugs and there is nothing to show that it diminishes attendances or TV audiences.
New drugs will be sought and unless the medical profession keeps abreast of developments, the athletes will turn to other assistance. Whether one supports a harm minimisation regime or totally disagrees with drug use, medical ignorance is the greatest bar to controlling drug use in sport. With the development of genetic manipulation there is certain to be a search for the best method of altering the genetic pool. The development of programs which can increase the EPO content of the body or eliminate myostatin is already under way and this will lead to genetically altered humans. Present day research into muscular genetics to relieve muscular dystrophies is almost certain to be applied to athletic endeavour.
As part of the drug testing program, blood sampling is being practiced without any thought given to the dangers involved. There are risks involved to the athlete and to the venipuncturist [ 20 ] The problem resulting from a needlestick injury involving a HIV positive athlete will not become apparent for 3 months. To whom shall this helper look for support to control the HIV positive state and possible AIDS in the future? This and the other problems raised by Browne need to be addressed before tragedy strikes.
To attempt to control or limit doping in sport the IOC together with governments formed the World Anti Doping Agency (WADA) and these two groups financed the venture. The management was vested in a former vice president of the IOC. This is a drawback as the IOC has been so tainted by corruption that any person allied with it will always be viewed with suspicion. This view is shared by McCaffrey and his committee [ 21 ] It is interesting to reflect how a representative who raises money one day and doubtless minimises the drug problem, can a day later be pursuing drug users. Using people in roles which appear to be directly opposed to each other raises suspicions of a conflict of interests and questions the intent of the individual and the employers.
Furthermore, WADA has a number of problem areas. The criteria for including a drug on the list are open to criticism [ 22 ] The first criterion is that the drug improves performance or has the potential to do so. Drugs have placebo effects so that any chemical has the potential to improve someone's performance and thus make it unavailable for other athletes. One has only to read the literature [ 23 ] about food supplements to realise that taking these is an offence. Several amino acids have been shown to augment performance by stimulating the production of Growth Hormone [ 24 ]. Will this lead to banning the foods containing the amino acid? The second criterion is that the substance may damage the athlete's health. There are not many substances that cannot damage an athlete's health when improperly used, either as a result of overdosing or an allergic response. This criterion virtually places every substance on the banned list. Even water! The third criterion is any substance that violates the spirit of sport. The spirit of sport is not defined anywhere in the code so this leaves the door open for WADA to place any substance in the banned list. When these criteria are considered, one realises there is no substance that is safe for anyone to take, including food. What will WADA do about recreational drugs? Will it be an arbiter of lifestyle as well?
How is the performance of WADA assessed? There are no performance criteria in the Code. Who appoints the members and for how long? What will be the standard for evaluating salaries for the employees? What will be the standards (ethics, conflicts of interest, criminal record?) for hiring and retaining staff? Do decisions have to be unanimous to ban a substance? Is there a specific cut-off date before events which would allow athletes to clear a drug which had previously not been banned? How long will samples be retained for testing? Currently it is 8 years but in theory WADA may keep them until a test is developed for a drug. The accusations and denials of the Lance Armstrong case shows what problems arise as a result of irrational fervour [ 25 ]. If WADA intends to test athletes' specimens in some future system, will they keep urine specimens of athletes who finished behind a suspect to ensure that new winner was drug free before they award a medal? How many placegetters behind the suspect will have specimens kept to ensure that the eventual winner was drug free? And what if they are all positive? Obviously to be fair every specimen of every athlete must be kept. The laboratory operators who evaluate other operators who wish to establish a drug testing laboratory for what appears to be an ongoing and lucrative activity, are themselves involved in the process of drug testing and there is a possibility here of a conflict of interests.
THE TRIAL OF A SUSPECTED DRUG USER IS BIASED AGAINST THE ATHLETE
The drug test is performed by WADA and the suspicions raised are pursued by WADA. The judge is WADA or a WADA appointee. If there is to be a jury, that too will be a selection by WADA. This is highly unbalanced and needs revision. The application of WADA rules is not uniform over the world. In Australia the athlete who is chosen for a random drug test is to be pursued by the police to ensure their attendance for testing. This gives a sinister aspect to the whole picture. The statement the athlete has nothing to worry about if no drugs have been used, does nothing to relieve anxiety. Police involvement is not a universal approach and unfairly penalises the affected athlete. As WADA has links to the IOC, there will always be some suspicion attached to this type of management.
It appears several basic legal rights afforded to most citizens of the world no longer apply to athletes when it comes to doping in sport. It is no longer necessary for an athlete to test positive as even "non-analytical positives" (perhaps hearsay?) are grounds for banning an athlete from competition.
To whom shall the penalty apply? WADA states the athlete is responsible for anything that is present in the body. This ignores the possibility of a planned attack on an individual by contaminating the food eaten. It is easy to distract an individual at meal time and then sprinkle a powder on the food to make the subject test positive. Similarly, sprinkling a drug over food at a buffet meal would be easy to do and render athletes drug positive indiscriminately. How could an athlete avoid this?
When rules are broken by officials, why are these people not penalised? Consider the most corrupt race of the 20th century, [ 26 ] Ben Johnson was positive to stanozolol and was penalised. At the time hormone tests were used as confirmatory evidence. These had not been approved for use but were used to convict him. Lewis was placed first but had previously been positive for nandrolone and was excused by his governing body on the grounds of his ignorance. Christie was placed second and was found positive to pseudoephedrine on the day of the race. He was excused by the IOC medical commission on the grounds it had been taken unknowingly. Others in the event had prior convictions. Surely the officials should have been named and banned just as happened to Johnson. This is as great a dereliction of duty as is the athlete's and needs to be punished in the same manner.
Judges in events have been severely criticised by the founding chair of W.A.D.A. but there is no public condemnation such as occurs with athletes. The sooner the playing field is levelled and offending officials are treated in the same manner as athletes, the more chance there is for a clear direction for top level sport to follow.
Drug testing is expensive and still has problems. The banning of specific levels of caffeine led to much debate before the acceptable levels were determined. There is evidence that the accepted testosterone/epitestosterone ratio is not at a suitable level to eliminate the punishment of innocent athletes [ 27 ]. This review showed levels above 6 were present in 27 athletes with no history of drug use. A similar state has arisen with Nandrolone [ 28 ] and these two variations from the accepted norms will render innocent people as drug takers. Much more work is needed to ascertain a reasonable ratio to protect the innocent.
WHAT CAN BE DONE?
An urgent review of the whole problem is needed conducted by people who have not been tarnished by previous experience. Previous experience with the monetary rewards systems for amateurs shows that with effort and understanding these problems can be solved. The questions raised above reveal the state of drug testing. It is unfair to the athletes and needs a total reappraisal to apportion blame equally.
There is nothing to suggest that doping will ever be eliminated. There has been no effort made to clean up the area that would inspire confidence. The best available option at this time is a harm reduction program. This would involve medical expertise of the highest calibre instead of those practitioners who are on the fringe of illegality. It would render the profit margins for illegal providers unattractive and gradually eliminate them from their markets which will cease to exist. Athletes would receive better advice and would use less drug. There would be more investigation of drug effects and a better application of knowledge for the benefit of all. There is a challenge for all sporting bodies to establish a system that offers the same opportunity to all in a free and open spirit. Have they the courage to face up to it?
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article should be cited in the following way:
Millar AP. Should Drug Testing be Banned.
The Doping Journal
Vol. 4, 1 (2007) Available at: http://dopingjournal.org/content/4/1/
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