DR RICHARD BUDGETT AND DR ARNE LJUNGQVIST

29 NOVEMBER 2006

  Q220  Dr Harris: Do you have anything to add on that, Dr Ljungqvist?

  Dr Ljungqvist: Yes. At the time when WADA was born which was before Richard Budgett came on to the List Committee, we on the List Committee made an attempt to make a new start of the List and change it completely. At that time, the Preliminary List did not include narcotics and did not include cannabis, cocaine, etc, etc, the so-called social drugs that are not performance enhancing drugs in our view, but it was rejected by the WADA Board and we had to revert to the original List.

  Q221  Dr Harris: There is an argument that, in that sense, that is a non-scientific approach, it is a more political approach and that potentially can be seen to undermine the confidence in the rigour of the scientific approach to the List.

  Dr Ljungqvist: We had to try to combat that and make the List credible. Of the three criteria at that time that I think you know of, two of them need to be fulfilled in order to have a substance or method considered for its introduction on the List, which means that performance enhancement is not a must, but if you say that it can be dangerous to your health or against the spirit of sport, then you can include anything on the List based on those two criteria because everything has health risks, ever medication has a health risk if you do not have a medical indication for its use, and it is of course against the spirit of sport that a healthy athlete takes a drug which he does not need. So, anything could be included but we have to exercise some commonsense. I am happy that there is room for commonsense as well. When Richard and I and others in the group consider some new substance or method, generally we always have in mind the performance enhancing aspect of it and that is known. The List is large enough, for sure.

  Q222  Dr Harris: My last question is to Dr Budgett. How difficult is it to be compliant with the Code for the UK? Is it a reasonable excuse for some countries to say that it is actually quite difficult without resources and therefore there has to be flexibility and time given particularly for countries with less resources and support and even in the UK?

  Dr Budgett: In my opinion, I do not think that large resources are needed to be compliant with the Code. It does need government time in countries because legislation may have to be changed to be in compliance with the Code, but I do not think that it actually needs resources. It does not say how many tests you have to do, it just says the structure you have to have in place and I think it is quite right that compliance is insisted on by WADA and the IOC.

  Q223  Chairman: Before I move on to Dr Turner, in terms of this review of the Code, I am interested in the compliance in the penalties. Is there anybody in WADA who is actually looking at the issue of disclosure? If we take Dwain Chambers who was using the Balco Laboratories, he received a two-year ban; he took the ban on the chin, fellow athletes lost their medals etc, but he retained most of the prize money that he won whilst he was competing having used illegal substances. However, he was not required to disclose, if you like, the pathway into Balco. Yet, to be able to deal a blow to the cheats is the most powerful weapon. Why is WADA not looking at that and making it a specific requirement: you cannot come back into the sport unless we have full disclosure of the pathway from where you were to where you actually acquired your enhancement? Why not? May I have an answer, please.

  Dr Ljungqvist: As you can probably understand, it is very, very difficult to answer such a question. The problem we face over and over again with athletes is that they simply refuse to disclose. Most athletes, as you are probably aware, reject the actual result of the laboratory test and say, "This cannot be mine. I have never taken anything." This is the routine answer that we get. You will remember the Ben Johnson affair when he said repeatedly over and over again that he had never knowingly taken anything. Not until he was under oath in Canada was it disclosed that he had been on a sophisticated doping programme for 10 years. We believe that most people who take steroids or serious doping substances are well aware that they are doing it, know very well where it comes from and are well aware of the risks they take. However, they do not tell us.

  Dr Budgett: The controversial thing which does happen is that there is an incentive for athletes to mitigate their penalty by revealing the background, how they obtained the drugs, who was involved, which athletes might be involved, and that came up in the Balco case, did it not?

  Q224  Chairman: Yes.

  Dr Budgett: Therefore, it can be effective and I would agree with Dr Ljungqvist that it is difficult because there may be the odd athlete who actually is innocent but has the substance in his urine—it would be very unusual but it could occasionally happen—but they are still going to suffer the penalty because of strict liability. Therefore, can you insist that they reveal from where they obtained the steroids when they do not know? I think that, on balance, it would be a sensible proposal that, before they are allowed back in the sport, they must tell the doping authorities where they obtained the substances.

  Q225  Dr Harris: With Dwain Chambers, was there not the issue where the more he admitted once he had been found, the more he was punished in respect of returning prize moneys? That was a huge disincentive for people to cooperate. Surely, like in many other systems in many other situations, people are not treated that way when they admit in order to encourage self-referral for colleagues. For example, in the medical profession, if you are going to be treated harshly when you admit things, it is a huge disincentive. Airline pilots are a good example. If you admit something, there is hardly any sanction because there are bigger issues to be tackled. Is that a problem?

  Dr Budgett: I have no personal experience of it but I am sure that it is a problem.

  Q226  Dr Turner: Dr Ljungqvist, there are those who sometimes question the validity of the criteria used for listing and others who raise ethical arguments about what should or should not be permitted as performance enhancing techniques. What factors do you feel should be taken into account when substances are included on the WADA banned list?

  Dr Ljungqvist: We do have the guidelines which are established in the WADA Code, namely the three criteria that I talked about. As I said, if you eliminate or disregard the performance enhancing aspect, you could place anything on the List based on the two remaining criteria. Therefore, we always have in mind whether those methods or substances have or could have any performance enhancing effect and, if so, we introduce them on to the List. We are very careful in introducing new substances and methods on the List because we know that, once they are on the List, it will be very difficult to take them off. We have had a few substances that we have finally been able to remove after a hard struggle. We are very careful. We have no other choice but to keep in mind the possible performance enhancing effect and that is where commonsense and I would say expertise knowledge comes into play.

  Q227  Dr Turner: It is a judgment call at the end of the day as well.

  Dr Ljungqvist: Yes, it is a judgment.

  Dr Budgett: I would echo that. It is a difficult judgment and, as Dr Ljungqvist said, the List Committee make a recommendation to the Board of WADA who make the ultimate decision which can sometimes be a political decision, but we base our recommendation on scientific opinion. As was said, anything theoretically can be up for consideration on the List. We on the List Committee I think quite sensibly consider that performance enhancing is the most important of the three criteria and you also have to weigh the therapeutic use of that substance. There is a balance as to how important it could be to somebody's health to be able to take that substance and, by putting it on the Prohibited List, are you limiting athletes' use of a perfectly valid medication against its potential for abuse and performance enhancement?

  Q228  Dr Turner: Are you happy with the List as it stands?

  Dr Budgett: I think I have already indicated that I am not.

  Q229  Dr Turner: Are there substances out there that you would wish to see included?

  Dr Budgett: Categories that I wish were not on the List.

  Q230  Dr Turner: Are there any categories and any substances that you do think should be on the List which currently are not?

  Dr Budgett: I personally think—and I know that a number are of the same opinion—that efforts should be focused on the real problems of doping in sport which is on the anabolic agents, the Erythropoietin and blood doping, which are the serious concerns we have. We are almost sidetracked and certainly those of us in the fight against doping in sport who are trying to educate our athletes spend an awful lot of energy on what I would consider to be peripheral issues, making sure that people do not inadvertently take a banned substance and filling out lots of forms for therapeutic use exemptions.

  Q231  Dr Turner: Dr Ljungqvist, what is your view on hypoxic chambers? They are certainly used for the purpose of performance enhancing. Why do you not place those on the Prohibited List? Why was the substance pseudoephedrine taken off?

  Dr Ljungqvist: With regard to hypoxic chambers, I will have to avoid giving a lesson here because it will take a long time to respond. It has been in use for decades in certain sports in certain countries including my own. It has been ethically reviewed and it has been debated. It was a fashionable way of mimicking high altitude training for a long time. More and more athletes experienced negative side effects and today it is not used as much as it was earlier on. A discussion came up in WADA because certain governments wished to know for sure whether these could be included in the List or not and what the status would be for the future. They wished to know whether they should make investments in further equipment of that type. WADA conducted an investigation and wide consultation which resulted in a clear message from our stakeholders not to include it on the List for various reasons and, if you were to ask my personal opinion, I would agree. First of all, you cannot differentiate for sure between the use of hypoxic chambers and the sort of normal high altitude training. Secondly, we could not establish that appropriate use of hypoxic chambers under medical supervision would constitute any harm to the athlete or be harmful. So, the two remaining criteria were performance enhancing and ethics. The Ethical Panel felt that it was not in accordance with sports ethics whereas others felt it was. So, there was a difference of opinion and the final outcome was the one I told you, that it is not included on the List. It has now been tested, it has been carefully evaluated and I do not think that issue will come up again. Those governments who wished to begin making investment have probably begun.

  Q232  Dr Harris: What is pseudoephedrine?

  Dr Ljungqvist: Pseudoephedrine is an example of a minor substance. If we are supposed to focus on the real problems—and I fully agree with Richard Budgett in what he said about that—we should try to take away all those of minor or hardly any importance. Pseudoephedrine for various reasons, scientific reasons and social reasons, was considered as such. It is widely available over the counter all around the world for any sort of minor cold, flu or whatever. It is an obvious substance which can be ingested by a simple mistake or whatever. That was one aspect of it. It has a very limited performance enhancing effect, if any, and it was deemed to be an unnecessary substance to have on the List. Now, a different scientific problem has come up which means that it is being reviewed again and there were arguments for having it reintroduced because the metabolism of the pseudoephedrine means that it can be metabolised into a substance which is on the List, namely cathine.

  Q233  Dr Turner: Are there not difficulties in deciding that a substance is of minimal effect in terms of performance enhancement when, in some sports, the difference between first and second place is a fraction of a second? So, quite marginal differences can produce very big differences in reward. Does that not make it a little more difficult?

  Dr Ljungqvist: It is part of the evaluation and, if you wish to take pseudoephedrine for the purpose of enhancing performance, you would rather have to take it in such an amount that you could get side effects, which is not good for your athletic performance. We had one other example where we have taken a substance of the List, namely caffeine which is a well-known stimulant to all of us but it was taken off the List for the same reasons as pseudoephedrine was.

  Q234  Chairman: Before we leave this section, what is the difference between allowing hypoxic chambers to be used—and we saw them in Australia in both the major sports institutes we visited there—and allowing a controlled use of EPO?

  Dr Ljungqvist: It is a huge difference.

  Q235  Chairman: I am not suggesting that, I am asking for an answer.

  Dr Ljungqvist: No, I fully understand. I think it should be generally understood that drugs, EPO or whatever, are intended for the prevention or cure of disease or alleviation of symptoms. It is on medical indication. As long as there is not a medical problem or a disease in a lead sport, then any such use is contraindicated and simply medical malpractice. The concept of controlled drug use for healthy young athletes should not exist. It is an impossible concept.

  Dr Budgett: I would also echo that there is a difference between mimicking what is available naturally and doing something which is totally unnatural.

  Q236  Chairman: Would you put laser eye surgery for an artery into that category?

  Dr Budgett: Yes, that is not available naturally and, if they do not need treatment. That is the whole wrong balance—

  Q237  Chairman: We will leave that hanging.

  Dr Budgett: Yes, let us leave that hanging.

  Q238  Dr Harris: I hate leaving things hanging. Let us not. I want to ask you about therapeutic use exemptions and I would like to ask both of you what you think the cause of this epidemic in asthma is among athletes. Previously in my medical training, I have never known it to be infectious.

  Dr Budgett: It is my personal opinion that because we in this country are the most efficient at filling out these abbreviated therapeutic use exemption forms in the British team, we have a reputation of having a much higher incidence of asthma than other Olympic teams at around 20%, which is about the same as the general population. In North America, the UK and Australia, it is a similar 20% incidence mass and that is what we have. Some on the IOC and WADA were concerned at this very high incidence of asthma and I suppose it goes back to the spirit of sport where, quite rightly, you do not want a culture of everyone having a puff on their salbutamol inhaler on the edge of the pool before they set off. You can put in rules to stop that happening and they have done that in swimming; you are not allowed to use your salbutamol inhaler on the poolside because medically you do not need to, it is not the appropriate place to use it and it stops everyone from thinking that they have to have a puff on a salbutamol inhaler otherwise they are not going to keep up with the person next to them. There was a problem at one stage of this culture of, if you do not have an inhaler, you are going to go slowly. We instigated a comprehensive testing of the whole of the British team, the Eucapnic Voluntary Hyperpnoea tests—are you familiar with those EVH tests—which is where you hyperventilate for six minutes with a CO2 mixture, which dries out the airways and is a fantastic mimic of exercise induced asthma, a very sensitive test, and you do a flow test afterwards and you see whether the FEI falls by more than 10% which is the criteria of the IOC and that showed that we had a very similar percentage. It was very useful for us. I was doing this enormous amount of work just for these therapeutic use exemptions but we found that the vast majority were correctly diagnosed as having asthma, about 80% of those who thought they did, and we also found a number, particularly sprinters, who did not even know that they had asthma, they just thought they coughed a lot after exercise. They were therefore significantly helped by then going on to the appropriate medication. A few who had different sorts of breathing problems, they were getting a bit of Stridor or other problems, needed inspiratory training and other help. There is no doubt that it did enhance our care of the athletes but I think at a huge cost because we spent an awful amount of time filling out these forms. The whole aim of it is obviously to reduce the use of salbutamol which is anabolic in very, very high doses. Dr Ljungqvist will be able to tell us but you can pick up those very high doses and we know that above a certain level salbutamol is considered anabolic in and out of competition. And there are corticosteroids, which I do not personally think should be on the List anyway.

  Q239  Dr Harris: What you are saying is that 20% of healthy non-smoking young adults have asthma.

  Dr Budgett: Exercise induced asthma.