Sport, Medicine and Health

The medicalization of sport?

Dominic Malcolm

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781317576372
• Edition: 1
• Topic: Medizin
• Subtopic: Sportmedizin

The relationship between sport, medicine and health in our society is becoming increasingly complex. This important and timely study explores this relationship through an analysis of changing political economies, altered perceptions of the body and science's developing contribution to the human condition. Surveying the various ways in which medicine interacts with the world of sport, it examines the changing practices and purposes of sports medicine today.

Drawing on the latest research in the sociology of sport, this book investigates the scientific discourse underlying the promotion of physical activity to reveal the political context in which medical knowledge and public policies emerge. It considers the incongruities between these policies and their attempts to regulate the supply of and demand for sports medicine. Through a series of original case studies, this book exposes the social construction of sports medical knowledge and questions the potential for medicine to influence athletes' well-being both positively and negatively.

Sport, Medicine and Health: The medicalization of sport? provides valuable insights for all students and scholars interested in sports medicine, sports policy, public health and the sociology of sport.

Chapter 1
Sport, medicine and health

An introduction

This book explores the complex and contradictory relationships between sport, medicine and health. It stems from the observation that while currently there is considerable evidence that sport is undergoing medicalization – the process whereby ‘a problem is defined in medical terms, defined using medical language, understood through the adoption of a medical framework, or “treated” with a medical intervention’ (Conrad 2007: 5) – the development is multi-linear and at times contradictory to sport as an institution and athletes as a population exhibiting a high degree of relative autonomy. The book evokes a re-consideration of two socially pervasive ideas, namely: that sports participation is a fundamental and necessary part of a healthy lifestyle (the sport–health ideology); and that elite sport rationally exploits science and medicine in the pursuit of competitive success. It does so by drawing on a wide range of empirical research based on interviews, questionnaire surveys and documentary sources and through a more rigorous and systematic cross-fertilization of the sociologies of sport and medicine/health and illness than has hitherto been undertaken. Underpinned by an Eliasian sociological perspective it is an ambitious attempt to explore these phenomena holistically, via the interaction of their macro, meso and micro manifestations, their societal, institutional and interactional spheres. We begin therefore by sketching the breadth of the contemporary manifestations of this nexus of relationships.

Contemporary manifestations of the medicalization of sport

The medicalization of sport is a global movement. In 2003 the United Nations General Assembly adopted ‘Resolution 58/5: Sport as a Means to Promote, Health, Education and Peace’, which pronounced that ‘Sport and play improve health and well-being, extend life expectancy and reduce the likelihood of several non-communicable diseases. … Regular physical activity and play are essential for physical, mental, psychological and social development’ (cited in Safai 2008). In the same year, the World Health Organization (WHO 2003) published Health and Development through Physical Activity and Sport, which identified:

a new challenge and at the same time a tremendous opportunity for the sports movement as a whole … [to] contribute uniquely and importantly to the promotion of public health and at the same time strengthen social credibility and accountability of sport.

(Cited in Bloyce and Smith 2009: 112)

In so doing the UN and WHO firmly located sport as part of the traditional domain on medicine.

Following this, the European Union Physical Activity Guidelines were approved (European Union 2008), Developing the European Dimension in Sport (European Union 2011) positioned sport as fundamental to physical activity health promotion, and WHO (2012) published Global Recommendations on Physical Activity for Health. The prevalence of such policies within Europe was illustrated in Promoting Sport and Enhancing Health in European Union Countries (WHO 2011). The documentary review underpinning this report identified 130 national policies published within the European Region between 2000 and 2009 (112 from the 27 EU member states). Analysis of a sample of 25 concluded that ‘all strategies mentioned health-enhancing physical activity and contained overall goals on participation in sport and physical activity and/or on health promotion’ (WHO 2011: 42).

The medicalization of sport was noticeably accelerated by what came to be called the obesity epidemic. According to Gard and Wright (2004), discourse about obesity consists of the following beliefs: (i) populations are getting heavier and that average body weight is increasing rapidly; (ii) obesity is a global problem; (iii) obesity is caused by lifestyle factors (such as the excessive use of computers, watching television, etc., which directly lead to a lack of physical activity); (iv) obesity is linked to a decline in self-discipline, traditional family values and parenting skills; and (v) obesity policy should focus particularly on children, because the behaviour of this population can most easily be modified and controlled. Indicatively, the UK Department of Health’s Tackling Obesities: Future Choices (DoH 2007) estimated that, by 2015, 36% of males and 28% of females in the UK would be obese. Although estimates vary, there is widespread consensus that obesity costs each state billions of pounds each year and that related costs are continually rising. In 2013, obesity ceased to be seen solely as a health risk factor, and became re-defined by the American Medical Association (AMA) as a disease in itself.

While the rhetoric continues, the predicted health crisis has not entirely emerged (UK obesity levels remained below 25% in 2013) and, despite extensive scientific endeavours, the links between obesity and (ill-)health remain uncertain (Gard 2010). The obesity epidemic has therefore entered a new phase signalled by what might be termed a shift from fatness to fitness, as calls have increasingly been made in the medical world to tackle a global inactivity pandemic (Piggin and Bairner 2016). Notable amongst such calls was the Lancet Physical Activity Series published in July 2012 (Lancet 2012). This collection of empirical articles and commentaries positioned physical activity as ‘the fourth leading cause of death worldwide’ (Kohl et al. 2012: 294), responsible for 6–10% of all 57 million deaths from major non-communicable diseases per year worldwide (Lee et al. 2012). Accordingly, an ever-expanding evidence base for the health benefits of regular exercise depicts regular physical activity as significant in reducing an individuals’ risk of suffering from breast cancer, colon cancer, diabetes, heart disease, hypertension and stroke. In total, it has been promoted as part of the effective management of over 20 chronic conditions (DoH 2011) including cerebrovascular disease, depression, osteo- and rheumatoid arthritis, osteoporosis and chronic obstructive pulmonary disorder (COPD). More generally, physical activity is thought to contribute to musculoskeletal health, workplace wellness and sustainable living (Jones et al. 2011; RCP 2012). Physical inactivity now constitutes one of the ‘big four’ proximate causes of preventable ill-health, alongside smoking, excessive alcohol intake and poor nutrition (AMRC, 2015).

However, central to distinguishing these trends from what might be termed the healthicization of society (Conrad 1992), is the explicit attempt to claim that ‘Exercise is Medicine’. The Exercise is Medicine (EiM) campaign launched in November 2007 as a collaborative initiative of the American College of Sports Medicine (ACSM) and the AMA (Sallis 2009) and is now established in 43 countries (Neville 2013). We discuss EiM in greater detail later in the book (see Chapters 4 and 6) but for now it is sufficient to note that this literal and metaphorical claim to the medicinal qualities of physical activity has been supported by one notable study, which concluded that: ‘exercise and many drug interventions are often potentially similar in terms of their mortality benefits in the secondary prevention of coronary heart disease, rehabilitation from stroke, treatment for heart failure, and prevention of diabetes’ (Naci and Ioannidis 2013: 1).

Concurrent with the processes defined above, it has become noticeable that sport appears to be increasingly dependent on medicine for its effective functioning. Perhaps most fundamentally, athletes’ (in)ability to participate is often biomedically determined. For instance, sport participation is frequently preceded by medical assessment of physical function/limitation, most notably in the boundary-blurring case of Oscar Pistorius who sought to run in both the London Olympic and Paralympic Games in 2012. Biomedical science has similarly been invoked to adjudicate upon the cases of Caster Semenya and Dutee Chand. The former was suspended by the International Amateur Athletic Federation (IAAF) for nine months after winning the women’s 800 m at the 2009 World Athletics Championship amid media speculation over her sex, while the latter successfully appealed to the Court of Arbitration for Sport (CAS) against her indefinite ban from competition due to the discovery of testosterone levels outside the ‘normal’ range for a female. Medical personnel similarly make key interventions during sports competitions. A particularly notable case involved the Bolton Wanderers’ footballer, Fabrice Muamba, who suffered a heart attack during a live televised game in an English FA Cup match in 2012. Muamba was treated on the pitch for over 70 minutes. He survived, but subsequently retired from professional football due to his underlying heart condition. The incident sparked debates about the role and value of cardiac screening in sport, which will be further explored later in this book (see Chapter 10). The management of concussion has also become a major issue (see Chapter 9), illustrated in the 2014 FIFA World Cup Final when Germany’s Christoph Kramer received lengthy treatment for a head injury, but was allowed to carrying on playing for a further 10 minutes. So high a profile has the issue become, that President Obama personally addressed the ‘Healthy Kids and Safe Sports Concussion Summit’ at the White House in May 2014. Yet, as illustrated by the sacking of Chelsea FC doctor Eva Carneiro in 2015, medical intervention in sport can be fraught with tensions as coaching/managerial staff seek to direct medical matters and question the expertise of healthcare professionals (BBC 2015a; see Chapters 7 and 8).

Concentration on such high profile incidents reveals the exceptional rather than the routine aspects of medical provision for elite athletes for, as Kevin Young (1993: 373) presciently remarked some time ago, ‘by any measure, professional sport is a violent and hazardous workplace, replete with its own unique form of “industrial disease”’. Recognition of this periodically re-surfaces in the campaigns of medical associations to ban combat sports, such as boxing and mixed martial arts. Less publicly but no less significantly, those bidding to host sport mega-events are obliged to promise a wealth of medical services and resources. For instance, at the London 2012 Olympic Games three ‘polyclinics’ were established at the main and two satellite Olympic villages. Medical support was also made available at each of the training and competition venues and, while partly dependent on the injury risk of the respective sports, generally included physiotherapy, sports massage, field of play recovery teams, athlete-dedicated ambulance services, sports medicine physicians and, in some cases, dental services. It was anticipated that a total of 3000 volunteers would be required to provide healthcare support at the games (EMJ 2008). Additionally there were 11 designated Olympic hospitals (LOCOG 2012) with 12 on-call consultants and regularly scheduled clinics (including cardiology, dermatology, neurology and surgery). The British National Health Service (NHS) provided physiotherapy and other musculoskeletal treatments, diagnostic imaging and laboratory tests at the request of national team doctors. In contrast to the normal means-testing system for British citizens, designated pharmacies provided free prescriptions to Olympic athletes. All this was in addition to the medical provision that national Olympic committees (NOCs) provided for their own teams and which normally deal with the vast majority of athlete injuries (Junge et al. 2009). The United States Olympic Committee (USOC), for instance, brought a reported 85 medical staff to support 530 athletes competing in London (Beaumont 2012).

While such interventions are sometimes predicated on the conventional medical focus of restoring health – for instance, in light of the surge in stories of professional athletes experiencing mental health problems, the English Premier League has made it compulsory for football clubs to appoint a mental health first-aider (Hughes 2014) – a distinct feature of medical practice in sport is the prominence of performance concerns. Sometimes these activities are routine but again, at their extreme, they have led to media controversy and indeed serious ethical questions about the work of healthcare personnel in sport. In particular, juridical cases and journalistic and autobiographical exposés have increasingly raised awareness of the degree to which elite sport is dependent on drug regimes. For example a Sunday Times (3 April 2016) investigation secured video evidence of Dr Mark Bonar’s claims to have provided illegal performance-enhancing drugs to 150 British elite athletes from sports including professional football, tennis, boxing, cycling and cricket. Bonar had previously been investigated by the UK Anti-Doping Agency (UKAD) which concluded that the privately practising, anti-ageing specialist was beyond their jurisdiction. They referred the case to the General Medical Council (GMC), which took no action and, by the time the media exposé broke, his registration had lapsed. While at the time of writing no legal action had been taken (collusion in performance-enhancement in sport is against GMC regulations but is not illegal under British law) the case bore considerable similarities to the 2013 prosecution of Madrid-based doctor, Eufemiano Fuentes (Malcolm and Smith 2015).

The ethical challenges endemic to sports medicine practice were particularly exposed in the ‘Bloodgate’ scandal in English rugby union in 2009 (Anderson 2011). The case involved the conspiracy of Harlequins RFC medical staff to: (a) fake a blood injury (thereby enabling a player to be substituted for tactical advantage); and (b) purposefully cut and then stitch the player in order to obscure the previous deception. The incident led the physiotherapist (Stephen Brennan) to be struck off by the Health Professions Council (HPC) after admitting supplying fake blood capsules to players (later repealed), and the club doctor (Wendy Chapman) to be reprimanded by the GMC after admitting intentionally causing a patient harm (she escaped harsher punishment after claiming extenuating circumstances of depression following treatment for cancer).

So fundamental is the medical ‘team behind the team’ for the everyday functioning of sport that certain facilities and individuals develop celebrity status. Notable in European football is the MilanLab, a ‘high tech interdisciplinary scientific research centre’ established in 2002 by Italian team AC Milan. The facility has been accredited with prolonging the careers of many Milan players, and has been supported by personal testimonies of celebrity footballers. For instance, treatment following the diagnosis of a dental complaint resolved David Beckham’s back problem which had, in turn, impeded his running. Subsequently Beckham was able to resume training and lost half his body fat (Brewin 2011). Within British sport perhaps the most notable healthcare provider of recent years has been Steve Peters. Peters was originally accredited with helping the British cycling team to unprecedented Olympic success in Beijing (2008) and has subsequently worked with Liverpool FC, the England national football team and snooker player Ronnie O’Sullivan. Peters describes himself as a sports psychiatrist (although sports psychologists are rather more prevalent in sport), and is famed for his approach to maximizing performance through enabling athletes to control their ‘inner chimp’. In the United States, surgeons such as Frank Jobe and James Andrews have similarly been feted for their contribution to saving the careers of a variety of elite sportspeople. Conversely, Stephen Dank became notorious for the ‘supplement programme’ he introduced at Essendon FC (an Australian-rules football team). Kept secret from the club doctor, Bruce Reid, the intervention of this sports scientist ultimately led to 34 past and present players being banned for doping offences (Crawford 2016).

Celebrity sports medics epitomize how the medicalization of elite sport impacts upon the broader sports culture; how ‘elite sport and the structures that support it, such as sports medicine, are at the forefront of public consciousness’ (McEwen and Taylor 2010: 88). For instance, it was as a consequence of an injury to the aforementioned David Beckham prior to the 2002 Football World Cup that metatarsals became cemented in the British lingua franca (Carter 2007). Clinicians anecdotally report that media coverage of elite sport influences patients’ treatment expectations (Milne 2011), and there was a reported rise in the public demand for sports physiotherapy services following the London 2012 Olympics (Owen 2012). While in the US it is not unusual for a doctor to pay in excess of $1 million for the right to be identified as the appointed physician to a professional sports team (Dunn et al. 2007), even in the more commercially limited UK healthcare market, the vibrant and growing private sector exploits links with elite sport. For instance, Dave ‘Rooster’ Roberts, a physiotherapist contracted to Lancashire County Cricket Club utilizes testimonials from elite athletes and, in particular, his most famous client, Andrew Flintoff, to endorse his private physiotherapy practice. Flintoff says:

His no nonsense approach to diagnosing, treating and rehabilitation numerous injuries over the years helped me get the best out of my body. A number of serious operations meant many hours in rehab but Rooster always gave me the confidence to know that I would recover and I trust his judgment. I know from my experiences, having seen him and his team of physios at close quarters, that no matter who you are you are always given the same high standard of care. Thank you!

Either because it is taken as indicative of quality, or because the primary demand for such services stems from sport injuries, private physiotherapy care is frequently marketed through a ‘sport’ appendage. Of the 15 ‘physiotherapy’ businesses identified in one UK county (Leicestershire) via a search of the online directory Yell.com, five used the word sport in their title, 11 cited sports injuries in their marketing, and another was physically located at a community rugby club (search conducted 30 March 2016). Notable in the above examples is the commingling of sports medical and para-medical professions in the media and public imagination (a point further developed in Chapters 7 and 8).

The convergence of both elite and mass participation sport, and medicine and health, is particularly well illustrated by the rise of urban marathon running. For instance, the London Marathon combines a race for international-standard athletes who compete for around £150,000 (Abbott World Marathon Majors 2015), with an event open to approximately 38,000 members of the general public. Here, then, elite sport and the exercising public both spatially overlap and, owing to the extensive physical demands, psychologically converge. The public can take part by either entering an open ballot (where approximately one in five applicants is accepted) or by acquiring one of the places guaranteed to charities, the vast majority of which raise money for medically-related causes. These charities attract runners via advertisements premised on a trope of the prevalence and severity of illness in modern society, the achievements of biomedicine and the prospect of more effective future treatment. Concomitantly, these events foreground participants as fundamentally healthy, disciplined and actively seeking self-improvement. Consequently, ‘the marathon as a media event and an embodied experience reflects and helps to perpetuate an individualization and medicalization of illness’ and thus might be considered ‘the most visible contemporary spectacle of health’ (Nettleton and Hardey 2006: 457).

Yet contrary to this, and largely hidden from public view, are the health costs of marathon participation. For instance, organizers of the London Marathon advise participants in this ‘spectacle of health’ that they should...