That said, even massive amounts of EPO don’t automatically lead to death. A 2006 paper described two hospitalized South Korean heart-attack patients who accidentally received nearly 10 times their prescribed dose of EPO—318,000 units instead of 33,000. Both patients were smokers, and one had a history of hypertension and diabetes. After discovering the overdose, the hospital closely monitored the patients for symptoms such as elevated blood pressure, nausea, vomiting, shock, and thrombosis (which had already put them in the hospital). Despite the overdose, doctors reported that the two patients experienced none of the negative expected side effects from toxic levels of EPO. While known reactions to EPO overdoses make for a long, serious list—headache, muscle and joint pain, allergic reactions, nausea, itching, seizures, enlarged spleen, elevated blood pressure, and overproduction of blood platelets—the doctors reported that “in the course of close observation, we found none of the specific symptoms we expected as side effects of erythropoietin, and no abnormal objective findings on physical examination.” The patients were soon discharged, and their EPO levels returned to normal.
In 1993, a wheezing, clammy-skinned man showed up at a New York emergency room complaining of shortness of breath and a cough. The frail 62-year-old repeatedly told the doctors that he needed a “transfusion to correct anemia” and that he was stricken by “chronically low hematocrit.” The ER doctors had a delusional hypochondriac on their hands with a history of self-medicating. The victim, a retired biomedical engineer, had a friend in the pharmaceutical industry who supplied him with Epogen. The arrivee had been injecting himself with EPO every day for several months (EPO is typically administered three times a week). He was also taking daily doses of a stew of other medicines, including penicillin.
When the patient checked into the ER, his hematocrit level was a through-the-roof 70.4 percent, a number that startled doctors used to finding a typical 42 to 54 percent hematocrit in adult males. While the fact that the patient was taking so many other drugs made it difficult to tie his symptoms to EPO alone, a report on the case in the American Journal of Emergency Medicine indicated that the months-long overdosing on EPO was causing the patient chest pain and hypertension, and it had worsened symptoms of his existing lung disease. The report pointed out that when a hematocrit level exceeds 70 percent, the amount of oxygen reaching the brain decreases, which in itself can be dangerous. In spite of his spectacular abuse of EPO, the patient recovered and was later released to a psychiatric hospital.
These vignettes are not meant to argue that EPO abuse is safe. It’s not. In their write-up of the case, the physicians took the opportunity to warn other doctors to be on the lookout for athletes who self-administer EPO: “It seems likely that an erythropoietin-induced increase in hematocrit, coupled with the dehydration that develops during prolonged exertion, would increase blood viscosity and cause impaired muscle perfusion and possible fatal thrombosis.” The point remains, however, that it is extremely difficult to find a case that backs up the press-supported notion that EPO was indiscriminately slaughtering cyclists in the early 1990s.
One reason European athletes may have quickly adopted EPO in Europe in the late 1980s is related to a difference in European and American patent law. Shortly after Amgen successfully cloned EPO in 1982, at least four other biotech firms and the University of Washington separately made the same breakthrough. A court battle handed the U.S. patent to Amgen. European patent law, however, is reluctant to grant patents on naturally occurring substances, and Amgen did not get an EPO monopoly on the other side of the Atlantic. As a result, Europeans had access to EPO from at least three manufacturers.
This pharmaceutical company competition, along with the buying power of Europe’s national health care systems, kept EPO prices much lower in Europe. The affordability put the drug within financial reach of struggling European athletes while the drug’s distribution from multiple chemical manufacturers may have created more opportunities for gray market product leakage. According to Alessandro Donati, an Italian sports professor and doping investigator, data from the sales of performance-enhancing drugs in Italy show that of 181 million prescriptions studied in 2000, the best-selling ones were erythropoietin and human growth hormone. The €158 million worth of EPO sold in Italy in 2000 did not include amounts brought in from Switzerland, nor the EPO distributed by the Mafia—much of it stolen from pharmacies or obtained from illicit distributors. Donati also cites a 1999 French study that indicated that only one-sixth of global EPO production went to patients with pathologies, with the rest being distributed through underground markets. Because there were more manufacturers of EPO in Europe than in the United States, Europe had more distribution nodes from which the drug could be bought or stolen, he says.
Interestingly, health care system differences ended up saving the lives of cancer victims in Europe compared to the United States. In 2001, Amgen released a new EPO called Aranesp. To spur product sales, the company offered $1,200 kickbacks to doctors for every prescription written. Amgen also ran a TV ad blitz that encouraged patients to ask for Aranesp as an antidote to fatigue. Prescriptions skyrocketed 340 percent in the United States, but increased only 52 percent in Europe. Across the pond, direct-to-consumer marketing is illegal, national health care systems use their buying clout to negotiate lower drug costs, and doctors in those same health care systems are immune to Big Pharma payola.
Five years after the Aranesp release, studies began to indicate that American cancer patients were dying 10 percent more frequently than European cancer sufferers. As it turned out, EPO was accelerating tumor growth; the American sales-and-marketing incentives that got more patients to take more EPO had the unintended effect of killing them off more quickly than in Europe, where patients were shielded from the pharmaceutical company’s aggressive sales-and-marketing efforts. While there is no evidence directly linking EPO to any competitive cyclist deaths in Europe, in the United States, there are ample data showing that heavy EPO use incentivized by the oddities of the American health care system was shortening cancer patient lives. This discovery lead to a sterner FDA-mandated “black box” warning on EPO packaging and a decline in American oncologists’ enthusiastic EPO prescription writing.36 The scandal also suggests how EPO’s black reputation in sports as a drug of mass destruction got an assist from drug makers’ efforts to expand product sales.
During a conversation with López over Skype, I mentioned Michele Ferrari’s infamous statement about EPO and orange juice. López said that Ferrari had dared to tell a truth that violated an anti-doping article of faith, one that firmly established itself after the IOC took its more aggressive anti-doping stance in the wake of the 1984 Los Angeles blood-doping episode: If it’s a performance-enhancing drug, it must be categorically destructive to health and the spirit of sport. In the severe catechism of anti-doping thought that was hardening after Los Angeles and the 1988 Ben Johnson scandal in Seoul, there was no room for a fact-based argument like Ferrari’s. Performance-enhancing drugs must be evil—end of story. For challenging the anti-doping missionaries’ creed by suggesting that the abuse of drugs is harmful, not drugs in and of themselves, Ferrari was immediately exiled.
“You cannot say Ferrari,” López observed. For his orange-juice comment, “he has been condemned. He is in hell and you cannot rehabilitate Ferrari’s image or respectability because received wisdom says that Ferrari is the devil.”
López was not justifying Ferrari’s acts. The Italian doctor repeatedly broke the laws of the land and sports, and he conspired to give certain athletes an illegal performance advantage that others did not share. He was banned for life by the U.S. Anti-Doping Agency for his involvement with Lance Armstrong’s doping and for administering and trafficking in performance-enhancing drugs. Even in 1994, he was up to no good. However, what interests López is how journalists who write about doping, and the agencies that create and enforce doping codes, can condemn Ferrari for speaking a truth about EPO when they have used the EPO-kills fabrication as a justification for a steadily growing anti-doping infrastructure.
López is not optimistic that journalists or anti-doping agencies will hold themselves accountable about the true health risks of doping any time soon. Doing so would be to spit in the soup that feeds them. It would also suggest that our responses to drugs are based more on personal bias than on hard data. “People are not interested in listening to other versions” of this colorful, body-strewn doping history, López told me. Excising the “doping kills” fable does no good for the anti-doping evangelists’ cause because the falsehood has self-justifying utility. As López put it, the EPO-kills story is useful as an anti-doping foundation myth. Like Knud Enemark Jensen’s “death by amphetamines,” the tale is factually ignorant but practically useful for the media and anti-doping bureaucracy’s “general condemnation and refusal of doping.”
As for the inherent ethical contradiction in the twisting of truth by anti-doping activists in order to return athletes to “true sport,” López does not think sinister motives are at play. Anti-doping agencies, scientists, and journalists are reluctant to discuss the fictional nature of drug-death stories because these tales serve a moral good that is a descendent of Coubertin’s quest for purity. The EPO-kills story “was useful for the anti-doping campaign,” López explained. “So it didn’t matter if the evidence was good enough or not because it was conducive” to the anti-doping missionaries’ goal of imposing a new purity on sports. In fact, López feels that anti-doping campaigners are acting in good faith, rather than willful hypocrisy. “I don’t think that they lied on purpose,” López told me. “But what they did was create a truth out of circumstantial and scattered evidence. And they believed in their own creation.”
About the Author
Mark Johnson is a sportswriter and sports photographer. He has covered cycling and endurance sports as a writer and photographer since the 1980s. His work often focuses on the business of pro cycling—a topic that frequently intersects with the sport’s long history of doping. Along with U.S. publications like VeloNews and Road, his work is published in Cycling Weekly in the UK, Velo in France, Ride Cycling Review and CyclingNews in Australia as well as general-interest publications including the Wall Street Journal.
VeloPress published Johnson’s first book, Argyle Armada: Behind the Scenes of the Pro Cycling Life, in which Johnson was embedded for a year with the Garmin-Cervélo professional cycling team. A category II road cyclist, Mark has also bicycled across the United States twice and completed an Ironman triathlon. A graduate of the University of California, San Diego, the author also has an MA and PhD in English Literature from Boston University. His other passion is surfing, which he does frequently from the home he shares with his wife and two sons in Del Mar, California. Learn more at www.ironstring.com, and follow Johnson on Twitter, Facebook, Instagram.