5:11 p.m. October 16, 2013

The Killing Point

To read Malcolm Gladwell’s “Man and Superman” is to be dangerously misled.

I first read “Man and Superman”, Malcolm Gladwell’s piece on performance-enhancing drugs, at two in the morning. Unable to sleep, I was slumped on the couch stumbling through the Internet in the hope that my reclined position and mounting sleep debt would gradually overpower a small, glowing screen full of text.

It did not. Barely a quarter of the way through the piece, sleep was out of the question. My hackles raised in resolute response to this glittering turd of ethically reprehensible journalism.

Flushed and fuming, I tore through the article once, twice, again and again. Blood pressure rising, I angrily emailed my colleagues, unable to contain my horrified indignation. Clusters of frustration and abhorrence bombed my insomniac brain, and I fought the urge to wake my sleeping husband, to howl with him at the sheer absurdity of it all. Because to read Gladwell’s “Man and Superman” is to be completely misled.

Gladwell cherry-picks his way through the complicated fields of physiology, genetics, and sport to frame an argument that is not only ill-informed, it’s downright dangerous.

His argument? Performance-enhancing drugs make sports fairer. Based on the premise that genetic differences make athletic competitions inherently unfair, he argues that athletes should be allowed to use substances to compensate for these differences. Not only that, he even suggests that it is perhaps more commendable to use pharmaceuticals than it is to be born “lucky.”

“What we are watching when we watch élite sports, then, is a contest among wildly disparate groups of people, who approach the starting line with an uneven set of genetic endowments and natural advantages.”

Riffing off of the book “The Sports Gene” (Epstein; Penguin/Current), and completely casting aside the 10,000 Hour Rule espoused in his bestseller, “Outliers” (Little, Brown and Company), Gladwell makes the case that if one person has a genetic advantage, shouldn’t everyone be allowed to cheat?

“We want sports to be fair and we take elaborate measures to make sure that no one competitor has an advantage over any other. But how can a fantastic menagerie ever be a contest among equals?”

The use of performance-enhancing drugs presents the chance to explore an interesting ethical dilemma. The problem, however, is in Gladwell’s omissions. His piece paints a rosy portrait of pharmaceutical enhancements. He likens them to the adoption of iodized salt. It has all the context of a sales pitch.

What Gladwell fails to mention - at all - are the risks involved in using performance-enhancing drugs. There is nothing about the risks of blood doping or of pharmaceutical enhancement. He even skips the risks inherent in the very genetic condition he holds up as “lucky.” There is no mention of contact sports, where the decision to illegally enhance could be the difference between life and death for your competitor. There is no recognition that healthcare access for athletes is a continuum with the Lance Armstrongs at the upper end, with their elite teams of morally questionable medical practitioners,and with some kid at the bottom end, desperate for a place on the team, taking injectables that he gets from a friend of a friend.

It’s cool, I read a thing in the New Yorker and PEDs are like, no big deal.

That Gladwell can proclaim the moral superiority of performance enhancement with no mention of the enormous physical toll that these drugs exact is fucking outrageous. Athletes are already testing the fringes of bodily limitations. Our blood, our hormones, our entire physical systems exist within certain parameters because those are limits that allow everything to work properly. Those limits keep us alive. So yes, of course it’s fucking dangerous to screw around with that shit. Of course there are consequences. People die.

In “Doping and the Story of Those We Love”, celebrated cyclist Greg Lemond and his wife Kathy share the harrowing story of Johannes Draaijer, a talented cyclist and newlywed who died of heart failure in his sleep. His wife Anna-Lisa woke up in the dead of night only to realize that she was sleeping next to the corpse of her beloved. Upon this horrifying discovery, she called Kathy, screaming into the phone with blood-chilling sorrow, “‘He’s dead! He is cold, he is cold. I am so afraid! Oh my God, oh my God!’”

An autopsy showed that Draaijer died with the shredded heart of a 70-year-old man. He was 27.


Nestled in the heart of Gladwell’s defense of performance-enhancing drugs is Finnish skier Eero Mäntyranta. A decorated Olympian and world champion, Mäntyranta is perhaps best known - at least, in certain circles - for his blood. Namely, that his body makes too much of it.

See, Mäntyranta has a genetic mutation, primary familial and congenital polycythemia (PCFP), that causes his body to overproduce red blood cells. This increases his body’s endogenous ability to oxygenate its tissues, which is a big competitive advantage for an endurance athlete. So much so, that people strive to achieve those results artificially. Of the three components of aerobic capacity - maximum cardiac output, maximum oxygen extraction, and hemoglobin mass - only hemoglobin mass can be well manipulated. And that’s where blood doping comes in.

Gladwell frames Mäntyranta’s genetic mutation as natural doping, making the case that since Mäntyranta’s blood is naturally more red-blood cell-dense, allowing other athletes to dope only makes things fairer. It isn’t technically wrong to call PCFP a kind of natural doping. What is wrong is the characterization of PCFP as a winning genetic lottery ticket. Aside from the fact that having extra blood doesn’t actually do the work of training, sufferers of PCFP face serious risks.

Clinical symptoms of PCFP range from headaches, dizziness, and nosebleeds to thrombotic and hemorrhagic events: that’s clots and bleeds, strokes and heart attacks. And then there’s the weird symptom of extreme itching after bathing. The symptoms can be relieved by phlebotomy - literally, blood-letting. However, even if they reduce the hematocrit (volume of red blood cells in blood), patients still have a risk of cardiovascular morbidity and mortality.

But Gladwell doesn’t bother mentioning the dangers that accompany such “dumb genetic luck”. And later, when he writes about EPO and blood doping, he doesn’t discuss all the cyclists who died in their sleep, their blood as thick as honeyed ketchup.

The reason PCFP is dangerous - and doping even more so - comes down to the limits of physiology: the sludge factor. Millions of years of evolution have resulted in whole blood that is (a) liquid and flows easily and (b) of a viscosity that the heart is accustomed to pumping. To overly simplify, blood doping is like turning your blood into molasses and asking your heart to keep up, all the while hoping that the sludge doesn’t get stuck anywhere.

The sludge factor, known as hyperviscosity syndrome, puts endurance athletes at even greater risk. To withstand dehydration, their bodies hold on to more fluids at rest. This alone would be beneficial to someone with an artificially boosted hematocrit, as it would liquidate the sludge and keep resting hematocrit levels low. However, for well-conditioned athletes, fluid losses are increased during exercise. An athlete starting with a boosted hematocrit at rest could very quickly move into the critical sludge zone.

Consider Johan Sermon, the promising Belgian cyclist who went to bed early in preparation for an eight-hour training ride. The team doctor had recently given him a complete cardiac evaluation and found him to be in an excellent condition. But his own mother found him dead in the morning. Heart failure.

Or maybe you’ve heard of the sixteen-year-old cyclist named Marco Ceriani? He had a heart attack during a race, after which he slipped into a coma and died. Fabrice Salanson? He settled into sleep in preparation for the Tour of Germany. His teammate awoke to find that he’d died in his sleep. Heart attack.

The list goes on: from January 2003 to February 2004, eight cyclists died of heart attacks. Compare that to how Gladwell talks about EPO, a chemical form of blood doping that triggers the body to make extra red blood cells, pulling a quote from “The Secret Race” by cyclist Tyler Hamilton (co-written by Daniel Coyle; Bantam) to frame his argument:

“People think doping is for lazy people who want to avoid hard work,” Hamilton writes. For many riders, the opposite was true:

“EPO granted the ability to suffer more; to push yourself farther and harder than you’d ever imagined, in both training and racing. It rewarded precisely what I was good at: having a great work ethic, pushing myself to the limit and past it. I felt almost giddy: this was a new landscape. I began to see races differently. They weren’t rolls of the genetic dice, or who happened to be on form that day. They didn’t depend on who you were. They depended on what you did—how hard you worked, how attentive and professional you were in your preparation.”

It is a vision of sports in which the object of competition is to use science, intelligence, and sheer will to conquer natural difference. Hamilton and Armstrong may simply be athletes who regard this kind of achievement as worthier than the gold medals of a man with the dumb luck to be born with a random genetic mutation.

It is one thing to write a compelling sales pitch, but journalism requires context.

Doping has killed people during races, leaving parties, at the dentist, in their beds. The excess of iron it produces can cause liver problems, including cancer. Bodies, inundated with repeated injections of synthetic EPO, risk the development of antibodies to erythropoietin, resulting in debilitating anemia as the body tries to fight the protein hormone responsible for triggering the production of red blood cells. And all the while there’s a heart straining under the sludge.

It is profound narcissism that says we all are entitled to the perceived specialness granted to others. What would we say of Mäntyranta if he hadn’t been a famous athlete? Who would want ketchup blood and purple, mottled skin? If you’re going to make the argument that iodized salt is a performance-enhancing drug that evens the playing field, shouldn’t we talk about ending global starvation and providing basic healthcare to all? Who is deciding the levels at which the playing fields of genetics, sport, life are considered fair?

Just look at this insidious horseshit:

“An athlete cannot use a drug to become an improved version of his natural self, even if the drug is used in doses that are not harmful, and is something that—like testosterone—is no more than a copy of a naturally occurring hormone, available by prescription to anyone, virtually anywhere in the world.”

This phrasing is incredibly misleading. We cannot accurately judge the safety of drugs used off-label to enhance performance because testing them in such a way would be highly unethical and dangerous. The side-effects that we do understand are known because of patients who take the drugs on a clinically necessary basis. Take for example, human growth hormone; it’s used to treat exceptionally small stature in children, and we know that too much of it can result in the symptoms of acromegaly, like large heads, hands, feet, and organs. But excessive human growth hormone in a healthy, active adult? How much is safe? What’s all the growth hormone going to be doing in there? How might this backfire?

And don’t even get me started on “naturally-occurring”. Of course steroids are naturally-occurring. Your body is making anabolic steroids right now. In fact, your body is making all manner of chemicals. But chances are it’s making the correct amount. Remember that whole thing about bodies and limits?

But still, to focus only on the narcissism of entitlement is to miss the much bigger, more nefarious issue with performance-enhancing drugs. Athletes don’t boost performance past normal human limits in a vacuum: their actions affect their competitors.

Few people know this better than neurologist and President and Board Chairwoman of the Voluntary Anti-Doping Agency, the venerated former ringside physician, Dr. Margaret Goodman.

“When someone is getting hit in the head for a living, [performance-enhancing drugs] certainly shouldn’t be allowable.”

I spoke with her at length about performance-enhancing drugs in contact sports, spending the better part of the conversation with mouth agape at both the ubiquity of enhancements and the unscrutinized danger they impose. But one only need look up Chronic Traumatic Encephalopathy, or CTE, to spot this dirty little secret. Our conversation was rife with grim reminders of football players who, upon autopsy, were found to suffer from CTE, high schoolers and college athletes with concurrent, unhealed brain trauma, former NCAA football players instructed to fail their baseline concussion tests, to bolster the odds they’d get back in the game. Fold in anabolic steroids that, along with boosting muscle mass, artificially boost healing, and things start to look scary. Harder hits, and a shorter healing time for the body - but not necessarily the brain?

“When the smoke clears and they start really looking at the studies of who developed [CTE], as far as amateur and professional athletes, when [they] start getting larger numbers and start really looking at the risk factors, you are going to definitely see that PED use contributed.”

Her voice is edged with determined frustration.

“When you amplify [the dangers of contact sports] via an athlete being on performance-enhancing drugs or using performance-enhancing methods, the risks become that much greater.

“To me, there’s just no right or wrong in this.”

The use of performance-enhancing drugs is an undoubtedly pervasive and complicated issue. This isn’t the sole purvey of cycling; it’s everywhere. From elite athletes to NCAA soccer players, athletes are slurping down, shooting up, and rubbing in untested, unstudied, risky, and potentially deadly cocktails of so-called enhancers. And there are no easy answers.

Like a metastatic tumor with tendrils snaked deep through the body, the issue of PEDs spreads in many different directions: autonomy, exploitation, money, psychology, desperation, and competition. It’s big and it’s messy and there are no easy answers or quick fixes. But it’s also small, private, and personal. This isn’t just theory. These are bodies: fragile bits of meat wrapped around bones responding to electrical impulses from a soft mass encased by a thick dome. It’s easy to forget that bodies are sensitive, fussy things. They demand that their components fall within thousands of specific parameters. Temperature, pH, hormonal levels, blood glucose and micronutrients are just a few of the many areas where a body must stay within a certain range in order to stay alive. Athletes who have already pushed themselves to the limits of human performance, who would like to push further, can and do so with the help of a variety of drugs and a supportive environment. Trainers, friends, competitors, doctors, all at the ready to help in the pursuit of the win. Don’t worry, everybody does it. Don’t you want to win? Take this, you’ll piss clean. Did you hear that the guy you're fighting is enhanced? So-and-so took this and got a full scholarship. You hear that what’s-his-name is on that new shit? If it was dangerous, no one would do it. Don’t worry. Don’t worry. It’s safe. Everybody does it. It’s only fair.

It’s a seductive world of limitless promise, but to buy into genetic determinism in sport, to use that as the basis of rationalizing risky, pharmacological glory, is a dangerous mistake.

And it makes Malcolm Gladwell an extraordinarily dangerous journalist.