FINA and WADA, Working for the benefit of our athletes

By Professor David Gerrard*
OBE CNZM MB ChB(Otago) FACSP FSMNZ

Introduction

FINA holds top tier status in the eyes of the International Olympic Committee, justified by a universal interest in elite aquatic sport underpinned by sound principles of governance by a respected International Federation. Notwithstanding this recognition we are reminded that our major stakeholders remain competitors who begin their journey as toddlers learning fundamental water safety, later choosing to enhance their technical skill that ultimately serves a recreational or competitive end. While a comparative few aquatic aspirants achieve elite status, the work of the FINA Sports Medicine Committee extends across this spectrum. In this brief commentary, the obligations of FINA to the WADA Code apply only to those at the tip of the proverbial pyramid.

Health and Fair Play

Since the formation of the World Anti-Doping Agency (WADA) in 1999, FINA has been a signatory to the WADA Code, the document that articulates the anti-doping philosophy for sport. Embodied in the Code are five International Standards that unify the anti-doping policies of international federations and government authorities. This instrument continues to inform the approach taken by FINA in ensuring that the health of aquatic athletes and fair play in our sport remain priorities. It is also notable that for several years, FINA has maintained significant input into the deliberations of WADA through its representation on a number of committees. Decisions made at WADA meetings have been influenced through the input of representatives with connections to aquatic sport. Currently the following individuals serve both organisations:

• Professor David Gerrard (Vice-Chair of the FINA Sports Medicine Committee) sits as Chair of the WADA Therapeutic use Committee.
• Professor Andrew Pipe (Chair of the FINA Doping Control Review Board) sits as Chair of the WADA Prohibited List Committee.
• Dr Jose Veloso (FINA DCRB Member) is a member of the WADA Health Medicine and Research Committee.
• Dr Margo Mountjoy (FINA Bureau) is a member of the WADA TUE Dr Susan White (FINA DCRB Member) is also a member of the WADA TUE Committee.

In addition, the voice of the athlete is heard through the invaluable contribution made by former swimming Olympians Kirsty Coventry, Matt Dunn (also a FINA Bureau Member) and Maria Martinez currently members of the WADA Athletes’ Commission.

When athletes require banned drugs

One of the five pillars sustaining the WADA Code is that of therapeutic use exemption, a concept arising from the need for doctors to provide appropriate treatment to athletes in accordance with best practice, even when this necessitates the use of a WADA “banned drug”. Provided there is compliance with clinical guidelines and diagnostic criteria, any athlete is entitled to justified medical treatment in an approved, consistent manner. Physicians with a responsibility to elite athletes also have a duty of care that extends their obligations to the articles of the WADA Code. However there is also an onus on every FINA athlete to ensure that their health care provider is aware that they may be subjected to anti-doping policy. Only then can we assure competitors, coaches, parents and officials that our sport remains “clean”.

The link between FINA and WADA is affected through the presence of the FINA Doping Control Review Board (DCRB). Under the stewardship of Professor Andrew Pipe, the DCRB, comprising experienced sport physicians and laboratory scientists, advises FINA on all anti-doping matters. On the other hand, the work of the WADA Therapeutic Use Exemption Committee provides an overarching philosophy to the appropriate medical care of aquatic athletes, respecting the Prohibited List and International Standard for TUE. At present, the WADA TUE Expert Group is chaired by Professor David Gerrard, himself a former Olympic swimmer, who also sits as Vice-Chair of the FINA Sports Medicine Committee. Such is the serendipitous link currently existing between these kindred organisations.

This relationship has particular impact across each of the FINA disciplines. And given that our cohort of athletes represents the youthful end of the competitive age spectrum, there are a number of medical conditions that reflect this demographic. Asthma, attention deficit hyperactivity disorder (ADHD), a range of allergic disorders and musculoskeletal injuries are amongst the conditions commonly associated with applications to FINA that implicate prohibited substances. To illustrate this, the following case studies provide examples of the variety of TUE applications that require the attention of the DCRB.

Case Studies

CASE ONE

An 18-year old female water polo player suffers an acute seasonal episode of allergic rhinitis (“hay fever”) on the eve of the national Olympic selection trials. She visits her family doctor for urgent treatment and he gives her a depot injection of a potent glucocorticoid (anti-­‐inflammatory) drug. This medication has the effect of reducing severe inflammation in her congested nose and upper respiratory tract and also the swelling and “puffiness” around her eyes. However after the administration of this drug the athlete informs her doctor that she is subject to doping control as a member of the registered testing pool for FINA. He confers with the WADA Prohibited List to learn that he has just administered a banned substance that will require an application for Therapeutic use Exemption. However he is uncertain how to cover this “after the fact”.

DISCUSSION

Clearly this athlete needed urgent treatment and her doctor could not be criticised for acting in her best interest. However both the athlete and doctor should have discussed her national status and obligations to anti-doping at the outset of the consultation. While this may not have changed the doctor’s treatment plan he would have been aware that supportive evidence from his clinical examination and consideration of alternative “non-prohibited” drugs would strengthen the case for TUE application. In this case there is the facility to apply for a “retroactive” TUE application on the grounds that urgent treatment was necessary in the best interests of patient welfare. The imminent Olympic trial was a further complicating issue. Elite athletes are strongly advised to attend specialised sports physicians who are more likely to be familiar with anti-doping requirements.

CASE TWO

A 14-year old male swimmer visits his family doctor accompanied by a parent. School reports, plus feedback from his swim coach, confirm a longstanding pattern of disruptive behaviour and an unwillingness to obey instructions. There is family concern that these are signs of attention deficit disorder or a variant of ADD. The doctor, after asking a few questions, concludes that ADHD is the likely diagnosis and she recommends treatment with methylphenidate (Ritalin), a powerful stimulant widely recognised as appropriate treatment for this condition. Five years later our swimmer, still benefitting from a daily dose of the same drug, is now a national champion with the prospects of swimming in a FINA World Cup event. His family doctor has been requested to make application to FINA for exemption to use a specified banned substance.

DISCUSSION

This case represents a scenario that is not uncommon in swimming. The history and response to medication would suggest that the doctor has made a correct diagnosis, however she has not fully complied with the WADA Guidelines. There have been no baseline psychomotor tests and no consultation with a physician specialised in disorders of this kind. Engagement with a clinical psychologist is frequently considered helpful in presenting supportive details however one of the consulting clinicians must be a specialist physician. Given that our swimmer is now approaching adulthood it is even more important for his clinical status to be reassessed. These specified requirements must be satisfied before the FINA authorities (DCRB) consider this application for the continuing use of methylphenidate. This case also demonstrates the need for doctors to be aware of their obligations to elite athletes and to comply with minimum diagnostic requirements.

CASE THREE

A 23-year old male springboard diver, in the build-up to his national championships, sustains a serious laceration of his lower leg in a trampoline training mishap. Two days later the wound, now grossly infected, requires urgent attention. He attends a local hospital Emergency Department with fever and groin tenderness. An Emergency Physician recognising the potential seriousness of widespread infection administers intravenous antibiotics combined with probenecid to delay antibiotic excretion, thereby prolonging the effect. Our diver is discharged on this regime with a note from the ED physician and instructions for follow-up with his family doctor. It is realised subsequently that probenecid is on the WADA banned list and a retrospective TUE application is made to FINA permitting the use of this drug.

DISCUSSION

This diver clearly needed urgent medical intervention and the protocol adhered to by the ED physician was standard hospital practice. The fact that there was an independent record of this treatment regime using probenecid was critical detail necessary for FINA to retrospectively approve a TUE. The diver rehabilitated well and his return to full health was uncomplicated, allowing the resumption of modified training and satisfactory preparation for his national event. This case reflects that the health of the athlete is paramount over any arbitrary anti-doping regulation. However in these instances the cooperation of the attending physician in providing supportive evidence to anti-doping authorities is critical to their decision-making and support.

Summary and Conclusions

Having both Chairs of the WADA TUE Committee and the Prohibited List Committee as active clinicians with FINA responsibilities, continues to ensure that all stakeholders remain well informed. However the education of athletes, their medical advisors and other members of the entourage is the foundation for effective anti-doping in each of the FINA disciplines. This is a joint FINA responsibility.

Such issues as changes to the WADA Prohibited List of drugs are communicated early to FINA where the deliberations of the DCRB are taken very seriously. In a similar way the WADA Guidelines written to assist physicians in their support of athletes with medical conditions have had their genesis in the experience of doctors who have cared for aquatic athletes.

FINA, by continuing to adopt anti-doping initiatives and by reflecting genuine concern for athlete wellbeing, places itself in a position of significant regard and high authority amongst kindred sports federations.

*David Gerrard is a physician and Full Professor in the Department of Medicine at the University of Otago in Dunedin, New Zealand. His clinical specialty is sport and exercise medicine. He Chairs the World Anti-Doping Agency Committee for Therapeutic Use Exemption, is Vice-Chair of the FINA Sports Medicine Committee and a member of the Anti-Doping Advisory Committee for World Rugby.

Professor Gerrard has an extensive background of peer-reviewed publications and book chapters on topics including paediatric and aquatic sports medicine, injury prevention, bioethics and anti-doping in sport. He was a 1964 Olympian and a Commonwealth Games swimming gold medallist who has also been NZ Olympic Team Doctor, Chef de Mission, and FINA Medical Commission member attending nine Summer Olympic Games.