A Global Perspective
The use of prohibited substances remains a global issue as evidenced by recent revelations of the high doping prevalence at the very elite level of sport (1), and is not confined only to Russia. Protection of the clean athlete is a top priority for the International Olympic Committee (IOC) and the World Anti-Doping Agency (WADA). The problem of doping in modern-day sport is exacerbated by the focus on winning at all costs. The winner gets fame, multimillion-dollar contracts, and becomes a role model for young aspiring athletes. For many athletes, especially from developing countries, modern-day sport is a social mobility tool, a means of survival, and a source of income for an extended family. This reality can lead vulnerable athletes to use any possible means to obtain success. The continuous exposure of doping by high-profile athletes serves to perpetuate the stereotype that doping is the only way to achieve sporting success (2–4).
Despite the imperfections, drug testing remains the main source of doping information to prosecute cases. It makes little sense, therefore, to start afresh, especially given recent signs of progress. What is needed is an evolution of sport, building on the successes of WADA (established in 1999) and reflecting recent cultural, economic, and social changes. Combating the use of prohibited substances and methods is complex and must be addressed at multiple levels. One recently proposed holistic antidoping approach is comprised of three primary pillars (3P): prevent doping, protect the clean athlete, and promote peak performance without doping (4). A key development that underpins the first pillar, prevent doping, is the 2003 World Anti-Doping Code (Code) and the subsequent code amendments of 2009 and 2015 (currently being redrafted). Effective deterrent features of the 2015 Code allow antidoping authorities to test intelligently, retest smartly (i.e., samples stored for 10 years), work collaboratively, and impose quick meaningful sanctions. There also is an increased emphasis on evidence-based education to correct widely held beliefs among those involved in elite sport, such as that successful competitive performance in high-profile sports is not possible without the use of prohibited substances and methods. Furthermore, the use of prohibited substances by athletes varies considerably based on the culture of the sport. Therefore, antidoping enforcement and education programs targeting vulnerable athletes participating in sports with greater risk of doping and from countries with a culture of doping will be more effective.
An essential component of the 3P program is protecting the clean athlete, which requires a paradigm shift away from the status quo, “the cheats are usually a step ahead” toward a new mantra “the testers must be a few steps ahead.” Rapid modernization of antidoping science will be required to accomplish this goal. Some positive signs that antidoping science is advancing are the investment by WADA and other sources (e.g., the IOC) to develop the next-generation antidoping tests involving “omics” methods (i.e., genomics, transcriptomics, metabolomics, and proteomics). Recent studies from numerous laboratories have confirmed the potential of transcription microarrays to distinguish changes in gene expression after blood manipulations and enhance the Athlete Biological Passport (ABP) (4). There is a pressing need to intensify research efforts that involve state-of-the-art technologies, such as next-generation sequencing (i.e., RNA-Seq), and to advance newer approaches, such as artificial intelligence (AI), machine learning, and deep learning, to identify new and more robust signatures of doping. These advances should significantly improve detection methods with particular reference to the ABP and the steroidal module.
The most attractive feature for elite athletes is the third pillar of the holistic antidoping approach, promote peak performance without doping (4). In particular, the development and application of innovative sport science strategies that enable peak performance without violating either antidoping rules or the rules of the sport. Modern-day sport is big business; no longer an amateur pastime for the privileged few, but a vocation for thousands of athletes and their extensive entourage of physiologists, nutritionists, biomechanists, psychologists, and the like. Developing impactful predictive and diagnostic performance metrics involving innovative wearable devices together with the capacity for real-time analysis of data also is needed to advance peak performance. Integrating these novel technological approaches will be a paradigm shift in performance enhancement with potential to be superior to the “traditional” prohibited substances and methods. This technological approach should be available to all athletes in the spirit of fairness to help the athlete, coach, sports physician, and sport scientist make informed decisions regarding efficacy of performance interventions, treatments, or injury prevention strategies. These new performance metrics also will potentially enhance the capacity to identify doped athletes through “intelligent antidoping” (i.e., targeted antidoping testing using performance metrics).
While all three pillars of the holistic antidoping approach are essential for successful implementation, advancing antidoping testing is critical to success as some athletes will try to combine holistic optimization of performance with banned strategies for even greater performance benefits. It is essential that all stakeholders supporting doping-free sport also invest in protecting the clean athlete, including sponsors, competition organizers, broadcasters, and all organizations that benefit from successful sporting events. Investment in antidoping by all stakeholders is important to the success of the program, given the current lack of investment in antidoping science. WADA has committed US $73 million (£52 million/€59 million) into scientific research since their formation (5). In comparison, this level of funding is much less than the recent transfer fee of one professional football player (6). The research budget of WADA also has been reduced considerably over the last 10 years with almost US $7 million (£5 million/€5.7 million) was spent in 2006 compared with US $1.5 million (£1.07 million/€1.22 million) in 2018, a reduction of more than 78% in a 12-year period (5).
On the Edge of a New Era
The 2016 crisis in Russian Olympic sport led to the suspension of the all-Russian Sports Federation and the Russian Olympic team from the 2018 Winter Olympics in PyeongChang, Korea. In response, Russia implemented a number of essential reforms at the legislative and social level. One significant change in 2016 was transferring the anti-doping laboratory, including blood testing, from the Moscow Anti-Doping Laboratory to the new anti-doping laboratory at the Moscow State University (MSU) that could, in the future, benefit from its 33,072-processor Lomonosov supercomputer (ranked 79th in the world). This change will help Russia become integrated into the international anti-doping solution. Another significant intervention was the approval by the Russian State Duma in November 2016 of Federal Law N. 392-FZ “On the amendments to the Penal Code RF and the code of criminal procedure of the Russian Federation (on stricter liability for violation of anti-doping rules)” outlining the penal responsibility for breaches of the anti-doping legislation by athlete support personnel (7). Sanctions for antidoping rule violations for coaches, specialists in sports medicine, and other athlete support personnel included a fine of 300,000 Russian Rubles (approximately US $4,500) or 6 months of salary, possible imprisonment, and a ban from holding posts in sport for 3 years. The use of intimidation, violence, or threat of force or violations involving minor athletes carries a sanction of 500,000 Russian Rubles (approximately US $7,500), 1-year salary, and a 4-year ban from certain professional positions. When doping occurs without the knowledge of the affected athlete, those responsible would face a fine of up to 1 million Russian Rubles (approximately US $15,000), a custodial sentence of 2 years or imprisonment of 1 year, and a 4-year ban from sport. The sanction for more serious offenses such as doping that leads to the death of an athlete carries a sanction of 3 years imprisonment.
In July 2016, the Russian Olympic Committee (ROC) also created the Independent Public Anti-Doping Commission to focus on reforming the Russian anti-doping system and reinstatement of the Russian Anti-Doping Agency (RUSADA). The Honorary IOC member and the Honorary ROC President Mr. Vitaly Smirnov headed this commission composed of sport officials, athletes, and members of the business community associated with sport, but specifically excluded representatives of the state government. From 2016 to 2018, RUSADA underwent radical transformational changes modeled on best practice among the National Anti-Doping Agencies enabling the new RUSADA to implement a multilevel system to monitor athletes and reduce antidoping violations. The Commission adopted a global National Anti-Doping Plan focusing on prevention of doping within Russia that expands anti-doping and process knowledge aimed at target audiences including athletes ranging from youth sport to the professional level, parents, coaches, doctors/physicians, sports managers, sports federation representatives, sports officials, sports program instructors, schools, universities, and the media.
A change in sporting culture from a doping paradigm epitomized by the statement “you are a fool if you are caught doping” to “you are a fool if you dope” will require implementing effective antidoping programs that promote clean sports. To be effective, these clean sports programs must be supported by professional athletes who serve as role models, athlete managers, sponsors, mass media, sports federations, and government institutions. Legislative changes may be required for full implementation to ensure uniform consequences for rule violators.
More than 1,750 male and female elite Russian athletes of different ages were surveyed to assess attitudes to doping. The responses were used to develop recommendations aimed at improving the interventions aimed at changing doping culture and reducing antidoping rule violations. Approximately 40% of the survey participants considered athletes who violate antidoping rules as fraudsters, who obtained performance benefits through deception. Notably, 33% of the survey participants considered athlete doping practices justified, while 25% believed that athletes found guilty of violating antidoping rules were victims of the current system. Based on these data, short-, medium-, and long-term goals were defined to instigate essential changes in the doping culture. Educational activities in antidoping focused particularly on fair play, sport integrity, and sporting values. At the same time, messages with a zero tolerance in doping were widely distributed.
In a relatively short time, the new RUSADA has implemented an up-to-date and forward-thinking antidoping educational program throughout the vast geographical area of Russia. For the athletes and their support staff, the program is made up of lectures, seminars, and training sessions. Specialist conferences and strategic sessions were developed for the national sports federations and representatives of the regional sport ministries to promote the regionally led educational strategies and antidoping programs.
A 2018 collaboration of RUSADA, MGIMO-University Business School, and the Russian International Olympic University, entitled “Ethics in Sports: Key Aspects of Anti-doping Activities,” was aimed at employees of sports federations, regional executive authorities, and sports organizations engaged in the field of physical culture and sports. The curriculum and all training materials were developed by RUSADA. During the training, participants had the opportunity to become familiar with pertinent examples from the fight against doping in sport and to get acquainted with the social and organizational context by which antidoping rules are applied. To widen the reach of the antidoping courses throughout Russia, RUSADA also has implemented online educational materials focused on basic knowledge in antidoping. Such courses allow athletes and their support personnel to familiarize themselves with antidoping rules and to test their knowledge from anywhere in the world.
RUSADA also is using AI by launching a “chatbot” in Russian and English aimed at younger users aged 12 to 27 years, where the user can check the presence of a drug on the WADA prohibited list and raise questions on any antidoping matter. There also is the plan to introduce virtual reality (VR) technology in 2019 that will allow athletes and their entourage to get acquainted with the doping control procedure in an augmented reality mode. As a culture of doping-free sport needs to be instilled at a young age, RUSADA developed a “school toolkit” in 2018 for beginners with materials intended for a parent-teacher meetings, a lesson about sport integrity and sporting values, and a fairy tale entitled “Dream to Win” narrated by the deputy director general of RUSADA that has been translated into three languages (English, German, and French) and also is available in a comic book version (8).
The philosophy of the reorganized RUSADA is to fight doping in sports with educational programs targeted at audiences ranging from schoolchildren and their parents to elite athletes and their support personnel, and all sports officials. A defining aspect of the new RUSADA is in transparency of the antidoping program implementation as evidenced by the regular updates of all educational material on the RUSADA website and social networks (available from http://rusada.ru/en/). A variety of outreach modalities are being used by RUSADA, from traditional lessons and lectures to future technologies, including VR and AI, to highlight its position of zero-doping tolerance. This message is essential to promote a culture of high performance elite sport without doping.
To facilitate this priority in doping-free sport, the ministry of sports of the Russian Federation has established an interdepartmental working group, which includes the ROC, RUSADA, the Ministry of Health, the Ministry of Education, the Ministry of Internal Affairs, the Russian Paralympic Committee, the Federal Customs Service, and a representative of the Council of Europe sports conventions division that is empowered to implement antidoping initiatives. A specialist responsible for antidoping support also was appointed in the field of physical culture and sports to each of the executive authorities of the Russian Federation. The task of these specialists is to inform the target audiences of expected antidoping rule compliance, the rights and obligations of the various parties, and a clear and fundamental understanding of the rules and principles of the antidoping process. These RUSADA specialists also coordinate and support all necessary scientific, educational, communication, and other social and public antidoping activities, including sport integrity, sport values, fair play, and antidoping support for athletes.
The efforts of the new RUSADA to be an active part of a global antidoping alliance in the fight against doping is evident with the presence of RUSADA specialists at most premier international professional events organized by WADA, the Institute of National Anti-Doping Organizations, the Council of Europe, as well as at events organized by national antidoping agencies and international sports federations. RUSADA experts are active in all functional areas ranging from education, risk assessment, targeted “smart” testing, investigation, scientific developments in the field of doping prevention, and doping control.
One such pertinent area in the fight against doping in sport is the procedure by which permission for therapeutic use exemption (TUE) of prohibited substances is obtained; a topic that has attracted considerable attention from scientists, specialists in the field of sports medicine, lawyers, and journalists (4,9–13). It is inevitable that athletes at all levels will fall ill during training and competition. Illness can vary from the common cold to serious illnesses such as cancer, which clearly require treatment. For instance, the prevalence of cardiovascular abnormalities among Olympic athletes for the period from 2004 to 2014 was reported at 3.9% (92 of 2,352), including serious pathological conditions (14). At the 2016 Olympics in Rio de Janeiro, 1% of athletes received a TUE for prohibited substances and methods (15). The TUE system provides athletes with health problems the opportunity to participate in competitions. This essential and legitimate system that protects the right of athletes to compete when unwell should not, however, be abused by those wishing to use medical treatments to improve their performance.
In recent years, the number of TUE requests has steadily increased around the world. In Russia, the number of applications increased from 48 in 2014 to 101 in 2018. In comparison, in 2015, there were 653 TUE applications by the United States Anti-Doping Agency and 429 by the French Anti-Doping Agency (12). The relatively low number of TUE applications in Russia may reflect the fact that the majority of Russian physicians involved in sport did not have sufficient knowledge to complete the TUE process. However, the knowledge gap is not only a Russian issue. For example, in a cross-sectional representative random sample 59-item survey about doping awareness among medical professionals in Slovenia, only 12% of general practitioners and pharmacists had worked with prescriptions of prohibited substances (9). Although 65% of the respondents considered their knowledge on doping and TUE sufficient, only 39% of respondents were familiar with the formal definition of doping (9). Similarly, a study by Dikic et al. (10) concluded that sports physicians involved in doping scandals were not aware of the nuances of doping rules and, most importantly, the list of prohibited substances. In addition, as athletes were punished for doping rules violations due to the physicians’ negligence, the authors advocated for additional education and training for physicians involved in the care of athletes. The percentage of the TUE requests approved can be informative. For example, the percentage of TUEs approved in Russia was only 19.2% (2016) and 21.8% (2018) compared to the respective National Anti-Doping Organization (NADO) in Germany (91.1% in 2015) and the USA (61.6% in 2015) (12). Main reasons for rejecting TUE requests are medical staff errors that may reflect a lack of understanding of the TUE requirements. Other common reasons for rejecting TUE applications in Russia include:
- submitting requests for nonprohibited substances/methods;
- lack of the diagnosis verification, that is, no documented records to confirm the diagnosis;
- lack of records on the use of alternative methods;
- unreasonable choice of method/substance;
- inconsistency with the wording of a request based on the standard requirements.
Since the formation of the new RUSADA, Russia has made great advances in the fight against doping with substantial support from the medical profession. Efforts to achieve fairness in sport should not be achieved at the expense of refusal of reasonable treatment. Bourdon et al. (16) surveyed elite athletes from France, Belgium, and Switzerland. Forty-six percent of respondents reported that they refrained from using medicines from the prohibited list, even though they had a therapeutic need (16). It is essential, therefore, that sport physicians treat athletes using protocols and standards associated with best medical practice and with the health of the athlete as the focus of decision making. When management of a disease warrants a prohibited medication, a TUE should be used to ensure the most appropriate treatment for the athlete.
Athletes, especially younger athletes, may be misled into believing that top results in elite sports can only be achieved by using prohibited substances and methods. This view is strengthened by the mismatch between the small number of adverse analytical findings (typically less than 2%) and the much greater suggested doping prevalence. An inevitable consequence of the professionalization of sport is the greater focus on winning, often at any cost. This modern-day reality also has led to a greater investment in science and medicine, especially by the wealthy developed sporting nations, yet there is an important need to clearly and consistently delineate what methods and technological developments are acceptable and within the rules of sport (including antidoping rules) and what falls outside of these rules. A greater investment in antidoping science and universal access by athletes to new innovations, such as in training, nutrition, sporting equipment, and the medical care of athletes, is essential to promote a culture of high-performance elite sport without doping for all athletes, irrespective of their country of origin. Universal adoption of such a change will, however, require athletes and their support staff to be convinced that the rights of the clean athletes are protected universally in the same way as will their opportunities for fair competition.
The authors declare no conflict of interest and do not have any financial disclosures.
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