What Is So Bad about EPO?

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The 1990s was an exciting decade for professional sports. Mark McGuire and Sammy Sosa each hit over 65 home runs in a single season, only to be topped by Barry Bonds a couple of years later. A cyclist named Lance Armstrong came on the scene, beat cancer, and won the Tour de France in 1999 (and then several more times in the 2000s). The same timeframe that saw these accomplishments, however, also saw the beginning of what some have dubbed the “steroid era.” The use of performance enhancing drugs (PEDs) picked up drastically in the 1990s, while testing for their use was behind-the-times. Today, random testing policies have decreased the incidence of PED use compared to the 1990s, but as the recent BioGenesis scandal and Lance Armstrong’s admission to using PEDs in his competitions from 1999 onward demonstrate, PEDs are still very much in the public eye.

Most people associate PEDs with anabolic steroids, which are used to increase muscle mass. But there is another kind of PED that increases the body’s endurance. Endurance has to do with how efficiently the blood can supply oxygen to the muscles. If you want to maintain a certain pace for a long period of time, you need to train your body to supply oxygen to your muscles efficiently. But, no matter how hard or long you train, there is a limit to how much oxygen your blood can carry at one time. If an endurance athlete could do something to change this upper limit, he would have a significant advantage over his opponents.

What Is EPO?

Blood has two main components: plasma and red blood cells. Red blood cells transport oxygen from the lungs to the parts of the body that consume oxygen, such as muscles or the brain. During exercise, muscles become oxygen depleted. The capacity to replenish that oxygen efficiently makes all the difference in endurance sports, like cycling, running, and cross-country skiing. The more red blood cells a person has, the more oxygen can be supplied per unit of blood. A typical red blood cell count (hematocrit level) for athletes is between 40-50%.

The body naturally makes a hormone called erythropoietin (EPO), which regulates red blood cell formation.[1] This hormone, predominantly made in the kidneys, responds to the concentration of oxygen in the blood. It is activated, for instance, when one goes from lower elevations to higher elevations; at high elevations, there is less oxygen in the air, meaning less oxygen in the lungs. EPO signals increased red blood cell production so there will be more oxygen carriers to re-supply the muscles.

In the 1980s scientists made a synthetic version of EPO to treat anemia, which was approved for clinical use in the U.S. in 1989.[2] Prior to the production of synthetic EPO, people on dialysis as well as cancer patients undergoing chemotherapy had to get blood transfusions to resupply their red blood cell levels; now, with the help of synthetic EPO, their bodies can make their own red blood cells.

As with many enhancement technologies, however, what started as a therapeutic technique became a way for an athlete to gain a competitive advantage. Self-injection with EPO became one of several techniques—along with training at high altitudes and receiving blood transfusions—used by athletes to increase their blood oxygen levels for competitive advantage in endurance sports.

Of these three techniques, only training at high altitudes, or simulating high altitudes with a hyperbaric chamber, is permitted. High-altitude training changes the athlete’s environment, but does not bypass any of the body’s natural processes in producing red blood cells. The problem with this technique is that it provides only a limited benefit to athletes because of the body’s natural limitations, and if there is a delay between altitude training and competition (due to travel or recovery), then the advantage further diminishes.

Accordingly, some athletes have turned to blood transfusions as a way to increase red blood cell count artificially. Some remove their own blood after altitude training to ensure that their red blood cell count is high, store the blood, and re-insert it right before competition. This technique often involves treating the blood so that the concentration of red blood cells is higher than normal. Blood transfusions are banned in most athletic competitions, but this ban has been difficult to enforce because there is no way to detect a blood transfusion unless the athlete uses someone else’s blood.[3] The drawback to this technique (beyond its being banned) is the difficulty of storing and transporting the blood samples. They must be kept at a certain temperature, and the transfusions must be done at just the right time.

Synthetic EPO provides a greater advantage to athletes and is much easier to use than the other two techniques. According to some studies, synthetic EPO can provide up to a ten percent athletic advantage allowing the athlete to maintain a certain effort level over longer distances. This ten percent advantage adds up over the course of an endurance race. This is also enough of an advantage that athletes who want to play clean will likely have difficulties keeping pace. EPO use in cycling likely came into widespread use in the early 1990s when world-class cyclists noticed a drastic change in the competition’s pace and endurance demands.[4] This is where Lance Armstrong comes in.

Why Did Lance Armstrong Test Negative?

In response to allegations of EPO abuse, Armstrong maintained that he tested negative, but later admitted that he had in fact used the drug. Synthetic EPO has been notoriously difficult to detect; athletes have found ways around tests that look for increased hematocrit levels. It was not until recently that tests have been able to distinguish between synthetic and natural EPO, and false negatives remained possible even after this development. By 2005 the tests had been significantly refined, and testers found that Armstrong’s stored blood samples—which had previously tested negative for synthetic EPO—now tested positive.

Ethical Considerations

It can be difficult to draw ethical lines in the case of EPO doping, but understanding the science behind it helps to clarify some aspects of the issue. One argument on behalf of EPO use maintains that the body naturally makes EPO, and using synthetic EPO amounts to the same thing as training at high altitudes, which is permitted. Shouldn’t the use of synthetic EPO, then, be permitted? Upon closer consideration, however, the proposed analogies with natural, permissible enhancement do not hold up. Synthetic EPO bypasses the body’s natural processes and causes the body to go beyond what it is designed to do. It brings about such substantial physiological changes that elite athletes like Greg LeMond could no longer compete against EPO users,[5] suggesting that synthetic EPO fundamentally changes the competitors—and the competition.

Sports are intended to be a competition among human beings. To fundamentally change the body or bodily systems such that they operate beyond the parameters of their design diminishes the dignity of the human being and promotes an instrumental conception of the body as a tool that may be used and manipulated in pursuit of one’s goals without regard to its intrinsic value. While breaking the rules is an important ethical consideration, a more fundamental concern is how the use of performance enhancers is part of a larger cultural trend towards commodification of the body and, ultimately, our dehumanization.


[1] S. Elliot, “Erythropoiesis-Stimulating Agents and Other Methods to Enhance Blood-Oxygen Transport,” British Journal of Pharmacology 154 (June 2008): 529-541.

[2] Ewen Callaway, “Sports Doping: Racing Just to Keep Up,” Nature 475 (July 2011): 283-285.

[3] Testers can look for elevated hematocrit levels, but this is easily by-passed using saline solution.

[4] Michael Shermer, “The Doping Dilemma,” Scientific American 298, no. 4 (April 2008). Shermer interviewed LeMond, who had won the Tour de France in 1986, 1989, and 1990. LeMond was set to compete again in 1991. He felt that he was in top physical condition, but contends that something was different about the competitors in the 1991 race. Riders who had not been able to keep pace with him in the past, were passing him without problems. LeMond believes 1991 was the year synthetic EPO was first put into wider use in cycling.

[5] Ibid.