Why I Don't Agree That Severe Asthmatics Should be Eligible for the Paralympics
German cyclists are arguing that there is "no place" in competitive, elite sport for people with severe lung disease. I don’t dispute that. Unlike his position, however, I do not agree that severe asthmatics should qualify for the Paralympics because of their diagnosis or treatments.1
I coach a Paralympic sport at the provincial level. And—like severe asthmatics, if they qualified for parasport—my athletes are probably not the first variety of para-athletes that come to mind when you mention the Paralympics, either. The sport I coach is goalball, and it is a sport designed specifically for athletes who are blind and visually impaired. Why is goalball a parasport? It was developed for athletes with a visual impairment (actually, to help rehabilitate World War II veterans who lost their sight in combat), and because my athletes cannot simply pick up just any ball and play just any sport--without modification. I’ve also done a small amount of work with wheelchair athletes—the ones that we most commonly think of when we consider parasport. I’m friends with a competitive wheelchair tennis player (who also plays sledge hockey), and also members of our provincial wheelchair basketball and wheelchair rugby teams. And a visually impaired swimmer who has competed at the Paralympic level.
Here’s where I see the difference between the para-athletes I’ve mentioned above and athletes with severe asthma.
1) Degree of risk.
I know I shouldn’t start here, but here it is. Yes: You can do pretty much anything with asthma. The difference, though, is that the difference between asthma—specifically asthma classified as severe—and a mobility impairment (to use the Boston Athletic Association’s wordage—in regard to sport, I’d classify visual impairment here as well, as the BAA would). While there is a risk of injury for any participant in any sport, the unpredictable nature of asthma could cause undue risk for athletes who have severe asthma. A compounding factor is that, as we know, environment plays such a big role in triggering or managing asthma. Many of us find travel challenging to navigate with asthma—now multiply these factors when competing at the Paralympic level, being in an unfamiliar competition environment. Sure, it’s a chance that the athlete is taking him or herself, and yes it’s based on “what ifs”. At the Vancouver 2010 Winter Olympics, a Georgian luger was killed in a fatal crash while competing. The shaking, heart-wrenching impact was not only felt by his teammates and the luge community, but every athlete, staff member, and spectator at the 2010 Games and those watching televised coverage worldwide. There is, sadly, potential for catastrophe on the world stage—and who could blame the International Paralympic Committee for not wanting to take that risk with individuals who already have a potentially unpredictable medical condition?
2) Therapeutic use exemptions are a fine line.
I’ve covered Therapeutic Use Exemptions (TUEs) previously, which you can read about here. Let’s go with prednisone which can be used for severe asthma exacerbations, or for maintenance treatment of severe asthma. Prednisone is banned in competition4 per the World Anti-Doping Agency. TUE may be acquired, but how can we prove there is a line between medical necessity versus performance enhancement in asthma? As much as most of us hate prednisone, receiving 60 mg of prednisone for a week prior to testing “did seem to significantly improve performance during submaximal exercise.”4
Now, the ethical question arises for the case of severe asthma: how do we draw a solid line for fair play with a drug like prednisone that undoubtedly helps with severe asthma maintenance or bad exacerbations, but may also be performance enhancing. (By the way, this is also true of albuterol/salbutamol and formoterol in high enough doses.)5,6
I think the answer is that we can’t. Does that play an ethical role here? I’m not the right person to determine that. One article does concede as well that the higher than average success rate of asthmatic athletes in competition could, perhaps, be influenced by the protective factors of asthma medicines on their airways, that go beyond even what a non-asthmatic might experience in certain environments—consider the 2008 Beijing Olympics, and arguments that yes, even Rio had air pollution issues that could be affecting athletes.5 Would any possible protective benefit work for people with severe asthma? Well, it rings true here, too: your asthma may vary, no matter how bad it is.
Doping: History in cycling.
For background, cycling has a doping history unlike any other sport—all athletes are under more scrutiny than ever for participating in clean sport, but cyclists probably feel this wrath the most.
Doping has been a part of cycling, especially the Tour de France for over a hundred years—so much a part of the sport that the rule book in 1930 reminded athletes that they would not be provided drugs at the event.7 Doping was not criminalized until 1960—performance enhancement tactics have a long history in cycling.7
Lance Armstrong may be one of the bigger names associated with doping in cycling, possibly due to his miraculous return to the sport after recovering from testicular cancer, but he’s not the only one by far—a teammate reports in court that as far back as 1997 drugs were being supplied to US Postal Service team athletes, and Epogen (EPO) was provided to some athletes, hormones like testosterone to others.6 Interestingly, EPO is one of the drugs that Armstrong likely was given in the hospital to treat anemia associated with his cancer treatment8. I have not read anything that explores any relationship between Armstrong’s EPO use and his cancer treatment in 1996—presumably, no such relationship exists.
Asthma physicians and researchers have enough difficulty determining a patient’s classification between moderate and severe and determining what phenotype of asthma is present.
Athletes with mobility impairments are classified based on their movement ability (or sight classification—how much vision they have) to ensure they qualify to compete, ensuring fair competition. Some athletes will qualify in one sport but not another2, and some sports only allow some classes or a single class of athletes to compete (such as goalball, only allowing blind/visually impaired athletes to compete)2. Cycling is one such sport: initially, tandem cycling was the only para cycling event, open to visually impaired athletes. It then expanded to include athletes with cerebral palsy, amputations and other neurological or locomotor impairments or disabilities—bicycles (standard and tandem), hand cycles and tricycles are used based on the athlete’s mobility needs.3 Classification is not an easy task, and changes in a person’s physical condition can alter their classification.
If we struggle to classify asthmatics clinically, how can we expect to provide a fair field of play in sport—especially with a disease that can change on a day-to-day basis? If an athlete’s breathing or lung function was worse on classification day than competition day, this could provide an unfair advantage and/or ultimately disqualify them. Just as mobility impaired athletes who do not meet minimum disability requirements. Any and all changes in physical ability may re-classify an individual (higher or lower) or even deem them ineligible to compete. Not only would medication use by severe asthmatics be under intense observation, any clinical changes would make classification and even doping control difficult.
I do not believe that the Paralympics are the place for athletes with severe asthma to compete in sport. While absolutely performance implications may—and do—exist associated with asthma, the modifications required to sport are a complete contrast to the sport experience of para-athletes. While athletes with asthma may require more time for endurance events due to their breathing or decreased lung capacity, the sport experience is otherwise roughly the same as for athletes. I don’t have a better answer, but I believe the Paralympics is not the correct one.
Have you ever gotten "moon face" as a side effect of prednisone?