Pulse
The Straight Dope
In international sports, doping is a race that pits athletes and coaches against medicine and science. When one team pulls ahead, the other is bound to be close behind.
Carolyn Bramante knows what it’s like to be on a short tether. Every three months between 2004 and 2009, the U.S. biathlon team member and University of Minnesota medical student had to fill out forms stating her plan for her whereabouts. If she deviated from the plan, she had to fax or email an update to the U.S. Anti-Doping Agency. Bramante, who competed in the 2006 Winter Olympics, knew representatives from the agency could show up at any time, follow her into a bathroom stall, and watch her as she filled a cup with urine. She was tracked down at home, in class, and in the library. “Once, I had someone come into a practice exam with me,” she says.
Such interruptions have become a routine part of elite athletes’ lives since international sports federations decided to form a united front and attack the issue of doping. “Everything came to a head in the late 1990s when the Festina scandal occurred at the Tour de France,” explains Mayo Clinic sports medicine expert Jonathan Finnoff, D.O. Festina was a French bicycling team and a favorite to win in 1998, the year one of its staff members, Willy Voet, was caught crossing the border between France and Belgium with, according to Voet’s account, coolers containing 234 doses of erythropoietin, 80 flasks of human growth hormone, 160 testosterone capsules, and 60 tablets of a Asaflow, a blood-thinning drug. Voet was arrested and fired from his job, and the team was ousted from the Tour.
Following the Festina fiasco, the International Olympic Committee hosted a meeting of athletes, governments, and all the major national and international sports federations. “What came out of it was the Lausanne Declaration, which condemned doping in sports,” says Finnoff, a former professional mountain biker and now a team physician for the U.S. cross-country ski team. As a result of the Lausanne Declaration, the World Anti-Doping Agency (WADA) was formed, and in 2004, WADA drew up an anti-doping code. Now all sports organizations involved in international competition must ascribe to it. The code spells out rules and regulations related to testing, the laboratories that can be used for testing, therapeutic use exemptions, and protecting the athlete’s privacy. It also lists the many prohibited substances and practices. Hence, the intense scrutiny of athletes like Bramante.
Better Blood
Doping in sports was a problem long before Festina. Throughout history, athletes have sought substances to enhance their performance. According to an article on the WADA website, strychnine, caffeine, cocaine, and alcohol were used in cycling and long-distance running in the 19th century. At various times, heroine, amphetamines, cortico- and anabolic steroids have been used by athletes to alleviate pain, provide energy, and promote strength. But doping in sports became infinitely more complex in the middle of the 20th century with blood doping—manipulating the athlete’s blood to enhance its ability to deliver oxygen to the body.
As early as the 1950s, people started to realize there was a relationship between red blood cells and a person’s performance, says Michael Joyner, M.D., an anesthesiologist at Mayo Clinic whose research focus is the physiology of oxygen transport. By the 1970s, scientific studies began suggesting that transfusing red cells could lead to improved performance in endurance sports. Joyner says the Scandinavians came up with the idea of transfusing people with their own blood, and by the 1970s, Finnish and East German runners were getting blood transfusions before races. The practice became widely known when the entire U.S. Olympic bicycling team admitted to having undergone homologous transfusions prior to winning four gold medals at the 1984 Olympics. The U.S. Cycling Federation banned blood doping in 1985. Other sports federations quickly followed suit.
The bans, however, did anything but put an end to it. First of all, doping worked too well. The riders, runners, and skiers who blood-doped won races. “Normally, people have a hematocrit of 44 or 45. After blood doping, it might be 48 or 50,” Joyner says. “It’s like horsepower in your car. All things being equal, if you have more horsepower, you can go faster.”
Second, blood transfusions (particularly with one’s own blood) are difficult to detect. The only evidence that an athlete had done it was his or her higher hematocrit and hemoglobin levels, which varied from athlete to athlete anyway, and the transfusion bags left behind in waste cans.
Third, in the mid-1980s a pharmaceutical company developed a synthetic erythropoietin (EPO) for people with anemia caused by renal failure. Athletes quickly discovered they could inject it and increase their hematocrit and hemoglobin counts without the hassle of transfusion. “If you’re going to use traditional blood doping to draw, store, and transport blood, you have a logistical challenge,” Joyner says. “But with EPO, it’s much easier to do. Just inject it with a syringe.”
By the 1990s, EPO use was alleged to be widespread in bicycling, cross-country skiing, biathlon, and long-distance running. A 2003 study published in the Clinical Journal of Sports Medicine that analyzed the blood of participants in the World Ski Championships found that 50 percent of medal winners and 33 percent of skiers finishing in the fourth through 10th places had highly abnormal hematologic profiles. Although athletes and their handlers knew there were risks to using EPO—its use was suspect in the deaths of 20 European cyclists—its benefits were so compelling that competitors were willing to take those risks.
Cat-and-Mouse Game
One of the risks was getting caught.
While athletes and trainers sought ways to perfect blood doping, the anti-doping community was working on ways to combat it. The initial idea, according to Finnoff, was to set a threshold for hemoglobin levels. If an athlete’s count was too high, he or she couldn’t compete. “So everybody’s hemoglobin values were right at those levels, and they kept them right there,” Finnoff says, adding that it would be unlikely to achieve this naturally because training tends to lower hemoglobin and hematocrit levels. He explains that the body compensates for fluid loss during exercise by retaining fluids, thus increasing the plasma volume in blood. “Historically, people who have been endurance athletes have what we call a pseudo anemia, which means that their hemoglobin and hematocrit are relatively low because of the increase in their blood plasma volume.”
By 2000, a test had been developed for EPO. But by this time athletes had found that by injecting microdoses of EPO, they could narrow the window when it could be detected to less than eight hours. A larger dose can be detected several days after administration.
Then new versions of EPO were developed by pharmaceutical companies. A bio-identical version that came out around 2005 couldn’t be detected by lab tests. And the slower-acting continuous erythropoietin receptor activator, which had a longer-lasting effect, could be taken less often so that the risk of being caught was unlikely.
By 2003, WADA had identified enough problems with testing for EPO that it sought other means for combating blood doping. An article in the journal Haematologica that year described a new idea to detect manipulation of blood: the hematologic passport. The passport establishes an individual reference range for a set of biological measures so that any abnormal variability stands out.
“Essentially, you try to determine what an athlete’s normal physiology is,” says James Carrabre, M.D., a sports and family medicine physician in Waconia who serves as a team physician for the U.S. biathlon team, is vice president of the International Biathlon Union, and is an independent consultant for WADA. “Athletes who swing outside of this [range] can be deemed to have an abnormal profile,” he says, explaining that the measures of interest are hemoglobin and reticulocyte count, which indicates how fast red blood cells are made by bone marrow and released into the blood.
Carrabre says the tests have to be administered at least three times over a period of time and done under standardized conditions. The athlete has to have been resting for 15 minutes and is supposed to be well-hydrated. The tests need to be done at low altitudes. The blood draw can take only 30 seconds. “These are examples of how picky the protocols have to be,” he says. Whether the blood passport will be the final move in the cat-and-mouse game between WADA and doping athletes is uncertain. An article in the New York Times last May discussed research from Australia and France that showed the passport failed to identify people taking microdoses of EPO.
Still, Carrabre thinks that WADA is on the right track with the passport. “It’s better than what we had before,” he says, noting that one German speed skater already has been sanctioned based on changes in her blood profile. “I think most athletes will back off what they’re doing rather than subject themselves to passport testing, which they will fail.”—Carmen Peota