Doping threatens to dim the lights of the 2024 Paris Olympics before it even starts. Reporting by the New York Times and ARD unveiled that 23 Chinese swimmers tested positive for the heart medication trimetazidine before Tokyo. The cases were not publicly announced and were excused after only 2 months based on an internal China Anti-Doping Agency (CHINADA) investigation that found kitchen contamination was at fault with spices, samples from kitchen drains, and also cooking hoods apparently testing positive for trimetazidine. The positive tests occurred during COVID precluding outside investigation of the incident and without any evidence to the contrary the World Anti-Doping Agency (WADA) said there was no cause for action. To make matters worse, three of the swimmers tested positive for clenbuterol previously, with those cases not announced due to the explanation of meat contamination. Three of them won Olympic gold in Tokyo, eleven will be swimming in Paris in eleven days.

To be clear, food or dietary supplement contamination is one of the most common causes of doping violations, it is also one of the most convenient excuses. It is a very real concern with drugs like trimetazidine or clenbuterol. Trimetazidine is a known international water contaminant and clenbuterol a known anabolic used in cattle production in some regions often illegally. This explanation must be properly vetted in each case in order to be accepted. A case involving suspected contamination would ordinarily be reported as an adverse analytical finding (AAF) and if investigation demonstrates contamination was the source the case may be excused with no case to answer, no sanction, or a reduced sanction could be given with an Anti-Doping Rule Violation (ADRV).

In the Chinese case the contamination explanation seems questionable on its surface. They literally threw the kitchen sink at the problem. Here, food contamination from spices is co-mingled with water contamination, which would be relevant with the drains and cooking hoods. If the spices were at fault, was enough of the drug really ingested to cause a positive test? These are spices not a main course. If water contamination, then why weren’t other athletes affected? We would likely see a number of similar cases in China and around the world if these were the real culprits? Water contamination could be investigated after the fact as it would likely still be present. It is hard to believe it would only be relevant on that day. The explanation does not appear to hold much water in our view, but we appreciate the dilemma faced by WADA in that their actions must be based on evidence.

In their statement WADA vigorously defended their actions. Knowing some of the folks that work at WADA we can assure you they take their job of defending clean sport extremely seriously. In an interview Olivier Rabin, WADA Senior Director, Science and Medicine, said the following. “In this case, despite our skepticism, a thorough review of all the verifiable facts of the case revealed no evidence to challenge the contamination scenario. Rather, all the available evidence pointed towards no-fault contamination versus intentional ingestion.”

The WADA statement noted some important facts. The cases were reported by CHINADA to WADA in June 2021. WADA reviewed the case file provided in June and July 2021, along with the scientific evidence and consideration of hypothetical scenarios, and ultimately decided there was no evidence to warrant any action on their part. They reported the cases to the International Testing Agency who challenged the potential misreporting of results in early 2022. WADA investigated those concerns and found no issues. USADA had contacted WADA in 2020 with apparently “unsubstantiated” reports of a whistleblower that had reported doping cover ups in Chinese swimming. USADA contacted WADA again in April of 2023 with a similar report in regards to the trimetazidine cases.

At the end of the day, anti-doping decisions like these shouldn’t occur behind closed doors as it creates an air of suspicion and doesn’t allow the relevant facts to be analyzed. There are protocols to follow in cases of inadvertent doping involving contamination. How those were managed here should be scrutinized and investigated. Perhaps the relevant scientific facts in the case file would legitimately support a kitchen contamination argument? How much trimetazidine was found in the urine samples?  How much was found in the spices, drains, and vents? We will never know if the facts are not made public as they usually are in anti-doping decisions. Those facts could allow external reviewers to consider the contamination argument. For the world to be satisfied these details must be released.

An independent review has been done by Swiss prosecutor, Eric Cottier, who in an interim report concluded, “All the elements taken into consideration by WADA, whether they come from the file produced by CHINADA with its decision or from the investigation procedures that it carried out, show the decision not to appeal to be reasonable, both from the point of view of the facts and the applicable rules.” 

This has not quelled the concerns. “The report confirms WADA failed to investigate the facts on the ground in China and failed to uphold its own rules,” a statement from Travis Tygart CEO of USADA says, “From the beginning, our goal has been uncovering the truth and the facts of this situation on behalf of clean athletes. Until WADA leadership shares that goal and stops spewing vitriol at any voice of dissent, there will be no trust in the global anti-doping system. In fact, today’s WADA rules by fear and intimidation, as their statements make abundantly clear. It’s time for a new strategy given that WADA’s credibility is crumbling before the world’s eyes and athletes deserve openness, transparency, and truth—not more deflection and bullying.”

Millions of eyes will be watching in Paris to see what happens next. The U.S. House Committee on Energy and Commerce threatened to withhold the $3.7 Million provided to WADA annually during a hearing June 26. Olympic Champion Michael Phelps said, “If we let this slip any farther, the Olympic Games might not even be there.” The DOJ and FBI are investigating the issue under the Rodchenkov Anti-Doping Act which criminalizes doping that impacts international competition with up to 10 years in prison and $1Million in fines. The Association of Summer Olympic International Federations (ASOIF) has now threatened not to hold any further competitions in the U.S. due to the concern saying, “”The U.S. criminal investigation into an anti-doping case on foreign soil, and the recent position of the U.S. Anti-Doping Agency, threaten to undermine the role and independence of WADA, and by extension, trust and confidence in the global anti-doping system and the autonomy of sporting rules and regulations.”

Many people have voiced their concerns over this issue but few solutions have been posed. Certainly the outlined protocols need to be followed and contamination cases properly vetted before expunging them. We also echo the sentiments to provide the relevant scientific details in this case for public review and scrutiny. Beyond those immediate considerations, the following thoughts are presented as ways to address the issues with long term solutions that we believe would improve the anti-doping system.

1. Keep Anti-Doping Independent and Improve Result Tracking

There was a time when political factors had more impact on anti-doping activities than the analytical results. We can’t let that happen again.  You can do the collections right, you can do the testing right, but if the adjudication is in some way impacted by political forces, favoritism, or a desire to protect high profile athletes then the system falls apart. This can’t be accepted as the norm.  Each case should be treated and managed according to established principles and there should be accountability in the system to ensure nothing can be brushed under the rug. It is amazing that in the modern era of anti-doping with all the systems and tracking in place that 23 adverse analytical findings from 2021 for Chinese swimmers can simply vanish for years only coming to light thanks to good investigative journalism.

This concern may necessitate an improved central tracking system and auditing system for collected samples to ensure there is a matching result reported based on the principles outlined and that reported results can’t simply vanish. WADA is responsible for tracking and reporting results. The WADA Intelligence and Investigations Department is tasked in part with enforcing the WADA Anti-Doping Code. There is an Independent Supervisor at WADA that audits the Intelligence and Investigations Department. To WADA’s credit the need for independent review and audit has already been designed and implemented.

However, this case suggests we need to add some robustness and broader independent review to the result tracking and audit process. Perhaps AI can assist in exposing and identifying issues. Statistical analysis can unveil potential issues as noted here.

2. Look in the Right Direction for Modern Alternatives to Performance Enhancing Substances

The doping agents of today are very different than those of the past. Drugs like steroids and stimulants are obvious choices for people who want to enhance performance, and low hanging fruit for those that want to address doping. These days, trimetazidine and meldonium are making headlines. This appears to show a shift towards use of new categories of substances like actoprotectors, antihypoxant, anti-ischemic substances that can act as metabolic modulators and aid in endurance or recovery. Antihypoxant drugs, like Hypoxen that is advertised for sports support by the manufacturer, are not yet banned. The CAS decision in the Valieva doping case that rocked the Beijing Winter Olympic Games in 2022 noted that Hypoxen was declared alongside trimetazidine and L-carnosine. Since trimetazidine was banned in 2014 and meldonium in 2016, no related substances have been added to the WADA Prohibited List in category S4.4 Metabolic Modulators.

Meldonium was the number one reported drug in 2016 with 515 adverse analytical findings. It is clear these drugs are popular and yet the system has not broadened the coverage of the category in almost a decade. In a USA Today story from 2017 Russian Federal Medical-Biological Agency head Vladimir Uiba was quoted saying Russia has found “several drugs which are not banned and work significantly better than meldonium.” Need we say more.

Research from 2011 on metabolic modulators noted, “Metabolic modulators are a newer class of drugs that benefit heart failure patients by modulating cardiac metabolism without altering hemodynamics,… more specifically they increase glucose metabolism at the expense of free fatty acid metabolism, thereby enhancing efficient use of oxygen.” In simple terms they improve oxygenation and blood flow, which has the potential to enhance endurance, recovery, and even strength in healthy human athletes. This paper discusses trimetazidine along with three other drugs that are not banned; ranolazine, perhexiline, and etomoxir. Folks this is how people dope, they look for banned substances in the research and try to find related substances that aren’t banned. Substances like Mexidol or Cytoflavin also appear to be alternative doping agents with antihypoxic and metabolic modulation effects.

We need to start looking in the right direction and responding quickly to new categories of banned substances that are likely to be used, like antihypoxant and anti-ischemic metabolic modulators, or nootropic cognitive enhancers. These are drugs on the edge of performance enhancement that allow for doping in the margins with alternatives to doping agents that have similar biological effects but are not yet banned.

3. Protect the Innocent from Contamination and Inadvertent Doping

How low is too low when it comes to sport drug testing? The concept of a minimum reporting level (MRL) has been formalized by WADA for certain drugs and likely needs to be expanded more broadly. Testing today is super sensitive capable of detecting down to 1 part per trillion or below (ppt, or picograms/gram). Detection levels are a thousand times lower now than a decade ago. This has the benefit of expanding the window of detection for doping agents, but also increases the possibility of causing harm to innocent athletes by detecting drug contamination in food, water, or supplements at trace levels that have no benefit on performance but may cause inadvertent positive drug tests.

The anti-doping system was built to protect clean athletes and it is imperative that we don’t let it turn into a system that does more harm than good. Protecting innocent athletes from inadvertent positive drug tests is just as important as exposing those who dope. Accidental doping happens more often that you might like to consider. UFC Vice President and anti-doping stalwart Jeff Novitzky said a little less than 50% of UFC positives come with, “either definitive evidence or evidence tending to show that those positive tests were results of contaminants and not purposeful doping.” In the Olympic environment John Ruger, USOC Ombudsman from 1999-2014, said in 2013 “between 40% to 60% of positive test doping results were inadvertent (non-deliberate) cases.”

This is why we have offered third-party certification for banned substances in sport at BSCG for more than 20 years in our Certified Drug Free program. The majority of athletes use dietary supplements or nutritional supplements to fuel their performance, and batch testing for banned substances offers the maximum protection possible against the risk of such products being contaminated. A recent compilation of dietary supplement surveys noted that out of 3,132 products analyzed, “more than 28% of the analyzed dietary supplements pose a potential risk of unintentional doping.”

We must recognize the risks of contamination and respond with science and sensible policy to deal with the concern. It should be noted that WADA has a committee, the Contaminants Working Group, dedicated to dealing with the issue.  In 2022 WADA formalized the concept of a minimum reporting level (MRL) in the WADA Technical Document TD2022MRPL, to deal with natural presence, contamination or other issues. Previously MRLs were outlined but not formalized. Considering MRLs for a wider group of drugs is likely justified but WADA tends not to acts until it has the science to inform the action. The body of science focused on contamination is slowly expanding allowing informed decisions on MRLs to be made and providing a broader set of data to consider in cases where contamination may be involved. More resources need to be spent addressing this concern so that scientific, instead of subjective, reasoning can be used in cases where contamination is suspected or claimed.

In the event an AAF is verified to be inadvertent due to contamination but a sanction is still deemed necessary a separate category should be considered for these victims so they do not have to bear the shame of an ADRV. Perhaps these should be called Inadvertent Rule Violations (IRV) to separate them from purposeful dopers.

4. Statistics Can Expose Issues with Nations and Compliance with the WADA Code

WADA testing statistics can identify concerns and lack of compliance with anti-doping case management. WADA publishes annual statistics that summarize the number of samples tested, initial adverse analytical findings (AAFs,), and verified anti-doping rule violations (ADRVs) by nation and sporting discipline. These figures can be used to evaluate the responsibility of nations and the response of the system overall to determine if procedures and policies included in the modern version of the Code are being followed. The theory being that if certain nations demonstrate statistical anomalies over time then asking questions may be justified.

The last available statistics for ADRVs are from 2020 a Covid year, so 2019 is the most recent non-Covid year. We look at the WADA statistics from 2019 to get a window into how certain nations approach drug testing. The number of samples tested, AAFs, ADRVs, percentages of both, and the conversion rate between AAFs and ADRVs is shown below for a list of 10 nations.

Comparing the U.S. and China we discover that the nations test roughly equal numbers of samples with the U.S. at 11,213 and China at 9,936. The U.S. had 194 initial AAFs with a rate of 1.73%, slightly above the overall average of 1.09%.  China meanwhile had only 14 AAFs with a 0.14% AAF rate, the lowest percentage of any country we evaluated and well below the average. The U.S. had 37 cases excused for medical reasons based on therapeutic use exemptions, 114 no case to answer that were closed at results management level, and 8 no sanction cases. China had none of these reported.

The difference in the AAF statistics and case management statistics is remarkable. It doesn’t take a statistician to realize that the U.S. and China appear to be approaching the application and adjudication of anti-doping very differently.

When you look at ADRVs the U.S. had 35 and an ADRV% of 0.31%, below the average of 0.65%. The conversion rate from AAFs to ADRVs was only 18% in the U.S., the lowest of any of the nations evaluated. The 114 no case to answer cases in the U.S. were by far the highest with the next closest nation having only 12, another anomaly that could be explored. China had an ADRV% of 0.12%, the lowest of any country other than Germany. China’s conversion rate from AAF to ADRV was among the highest at 86%, with only Russia (88%) and Iran (97%) higher, with the average being 60%.

Germany has become one of the most committed nations when it comes to anti-doping and it shows in the statistics.  They test 15,789 samples, more than any other nation by far. They have the second lowest AAF% at 0.32% and the lowest ADRV% at 0.11%. AAF to ADRV conversion is near the lowest in the countries reviewed at 34%, suggesting that they follow the Code and provide resources for investigations and education.

AAF to ADRV conversion is interesting to consider.  In nations that report and investigate all AAFs one might expect this statistic to be lower. In nations where resources are available to perform investigations to consider inadvertent contamination or other explanations the AAF to ADRV conversion rate might also be expected to be lower. In hard line nations, or those that suffer from a lack of education or resources, conversion rates might be expected to be higher.

Across nations nearly 12% of athletes who test positive initially and have an AAF reported ultimately had an explanation other than doping or medical use (228 no case to answer or no sanction cases out of 1,991).  348 cases are still pending from 2019. Why after 5 years we might ask? The statistics are not complete but 12% appears to represent a fairly high rate of inadvertent doping.

There is power in numbers folks and some of these statistics are eye opening.

Instead of burning bright, the Olympic torch will be flickering again thanks to this Chinese doping quandary. Hopefully more proactive efforts and solutions can be pursued to ensure clean athletes remain at the forefront of the Olympic movement and on the top of the podiums in the future.