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Sports Medicine in our National Federations: the case of developing countries

Developing countries face many health-related challenges in providing competitive opportunities for their aquatic athletes. In many cases the challenges to athletic development and success are a reflection of those present in the culture or nation generally. Several points will be covered in this article:

- Improving the health of the athlete and the availability of health care for athletes
- Focus on preventative health care
- Maximisation of limited resources to improve performance and health
- Ongoing training on the topic of doping control, to include situations that would place athletes at risk of a positive test

CONTEXT

Developing countries constitute a large part of the membership of FINA and they are confronted by important and varied issues necessary for the growth of all of the Aquatic Sports. Overall, these federations have evolved as totally volunteer driven, with a minimum of administrative support within the organisations. This has resulted in an accumulation of technical and administrative tasks to be performed by volunteers. In this context, sports medicine may not be able to be viewed as a high priority in relation to the many of the other requirements of the federation. These subjects, as they pertain to FINA disciplines, will be addressed here. We will first try to show why it is so important to address medical topics and then give some simple recommendations that can serve as a guide to address important medical objectives.

OBJECTIVES

Before making recommendations for aquatic sports medicine in developing nations, we should first describe the objectives for a sports medicine programme in these countries.

1) To improve the health of athletes

• Better education of swimmers and coaches is key.
• Acquisition of knowledge will not only serve the aquatic athlete, but also will also be useful in their family environment and community. It is clear that they may suffer from insufficient access to correct medical information.
• Good health, and education about health can bring added value toward the career of the aquatic athlete. These athletes may not end up with a  sport career but they will learn other things from their sport experience to help in their community and country.

2) To prevent severe consequences

The State is virtually the sole source of funds for federations in developing countries. Therefore, one must do everything possible to bring honour to the sport federation and help it serve as examples to upcoming athletes. Doping allegations create an entirely different set of problems that can detract from the immense amount of work and sacrifice that the athlete has made.

• Coaches, athletes and administrators face the same difficulties that other National Sport Organisations do when confronted by an athlete testing positive for a drug test by a doping control agency. The outcome can be much more difficult to handle because of the limited resources of a completely volunteer structure.
• Prevent tragic situations for the athletes, which can result in severe illnesses and injuries as well as catastrophic accidents, with the very limited resources available to the sport federations to assist the aquatic athlete.

Therefore the goal of enhancing sports medicine in developing countries has a dual interest in the long term and short term effects on the health and medical education of aquatic athletes. We must also prevent the severe difficulties that can result in tragedy, which can bring a stop to the development of any of the aquatic disciplines.

3) To leverage the scarce resources that are available

It is very expensive for a country that has low to medium resources to send its aquatic athletes to an international competition. The cost is even greater when an athlete sent to the competition cannot compete to the best of their ability because of an illness that could have been prevented if simple precautions had been taken. Even if they are not facing illness during the international aquatics event, their training may be interrupted by illness. Not all illnesses are easily prevented, but many illnesses in developing nations are preventable.

RECOMMENDATIONS

To address these objectives, here are some simple recommendations that can be reproduced in practically all of the developing countries:

1. A first step would be to designate an official who is a medical practitioner for each National Federation. This health care professional could then contact a member of the FINA Sports Medicine Committee with any questions or concerns, or other National Team medical personnel.

If possible, all Federations with their present membership structure should include a medical practitioner. This practitioner needs to be familiar with the needs of the country and its population and practice medicine within its borders. Preferably, the physician should be an integral part of the federation and live the realities of the federation.

Alternatively, the physician may follow the activities of the federation from afar but will be involved in activities when there is a trip to view. The physician should manage all medical issues of the Federation. Having such a physician may benefit the National Olympic Committees (NOC) training proposal. In the absence of these first two opportunities - to involve a physician in the activities of the federation - one can solicit the NOC’s physician, who can become the referring doctor where a designated doctor is necessary. The NOC doctor will have the advantage of being experienced and can be very useful.

2. In March 2009, the International Olympic Committee (IOC) developed a Consensus Statement on Periodic Health Evaluations of Elite Athletes. A past medical history review and a physical exam would be required of each athlete based upon this standardised format. The Statement has the benefit of requiring both an annual medical review and annual physical monitoring. For ethical reasons, these records should be managed by medical personnel only. It may be necessary to direct some cases for further confidential investigation. The Statement is available at the IOC Web Site, www.olympic.org, or by simply using the google search engine and name of the statement.

As an example, in some countries, repeated throat infections can cause rheumatic fever (RAA) with heart complications (heart valve). In this case, nothing but the examination can provide early detection and avoid situations which may present danger to the athlete due to inadequate heart function under the stress of training or competition. Ongoing surveillance would facilitate early intervention with antibiotic treatment for the infection which may result in rheumatic heart disease, if left untreated. Access to health care is as necessary as just an annual check-up. In addition, similar analogies can be drawn to other infections which may affect the heart, caused by bacterial, viral or parasitic sources. The heart is a simple example of the potential that ongoing access to care can have. Similarities can also be drawn to any organ system or problem. It is important to recognise that prevention is relatively inexpensive since it results in early treatment. Treatment of advanced disease is expensive, with diminishing returns.

3. Ensure your athletes have vaccinations. After the age of 5 years, very few people are regularly and normally vaccinated in developing countries. This corresponds with the ages that are supported by the expanded free immunisation programmes. This concept is difficult to grasp since the cost of caring for patients with these preventable diseases as well as the loss in productivity far outweighs the cost of ongoing immunisation programmes. It is important to continue this care longitudinally since the children are already in the supported system. It is important to note that the people currently do utilise the immunisation programmes until the cut-off age. Thus, it is not the lack of willingness to seek preventative care or to recognise its importance. The medical follow-up of all your athletes should operate at the higher level of vaccinations to prevent many of the infectious diseases that exist in developing countries. Also, using national athletes to set examples that encourage vaccinations for children seems a natural extension of their influence on youth.

4. Perform a systematic deworming every 6 months for intestinal worms, which often cause anaemia and decline in muscle performance and stamina in areas where these parasites are prevalent. Prevention always outweighs the expense of treatment, as noted above. The impact of parasitic infections on the developing athletes of any country will rob athletes of strength and educational development. While it is true that an occasional athlete will rise above the challenges of the environment, many athletes do not realise their potential, either in aquatics or their careers due to preventable illness.

5. Ensure that your athletes make regular visits to the dentist to diagnose and treat any cavities, and to have their teeth cleaned and scaled to prevent the development of cavities and gum disease. To do this, one must take advantage of mass campaigns offered free of charge by the Ministries of Health to the citizens of the country. Poor dental health has been tied to the development of future heart disease in adults. The lack of dental health is also linked to population-wide nutritional deficits. Both rob the society and athletes of potential. Poor dental health and oral infections can also affect athlete performance.

6. Consider pre-competition treatments for sources that can present as a febrile illness during the competition. This would include the time immediately leading up to the competition with the critical training that immediately precedes major events. Malaria is a perfect example of such a disease. It is detectable, treatable and fairly predictable in its behaviour. Endemic areas are easily identified with treatment of affected athletes, as well as preventative medication for when the athlete returns to visit those same endemic areas.

7. Perform free blood sampling to diagnose Hemoglobinopathies (sickle cell anaemia and thalassemia as examples) and sexually transmitted diseases (HIV, hepatitis B and C). Early diagnosis allows early treatment and maximisation of potential. Although none are as effective as health care standards which eliminate exposure, these simple tests could decrease the suffering from these illnesses tremendously in developing countries.

8. Train coaches, administrators and aquatic athletes regarding doping control procedures and knowledge about the subject of anti-doping. This would involve several levels of intervention. First, awareness of what is and is not considered doping for the sport in question. This can be done quite easily by using the tools available on the WADA website. Entertaining quizzes are available for athletes and coaches to aid in their understanding of the compounds in question. Doping is an ongoing problem in all of the elite sport. FINA has an advanced doping detection system. However, the coaches and athletes need to understand not only how it works but what they can do to avoid exposure to doping substances.

In closing, when resources are scarce, their use must be directed toward prevention. Treatment of preventable medical illnesses is always more expensive than prevention. The cost of a disease includes the lost opportunity athletically as well as productively following retirement from competition. The sports medicine practitioner in developing countries should advocate to provide vaccinations, parasitic care, dental care, and diagnostic blood testing to the country’s athletes. These, combined with education have the potential to make a dramatic impact on athlete performance and on any developing country’s sports programme.

*Dr. Mohamed Diop
FINA Sports Medicine Committee Member
CANA Sports Medicine Committee Chairman
CANA Bureau Member
President of the Fédération Sénégalaise de Natation et de Sauvetage
President of the Medical Commission of the Senegalese National Olympic Committee (2001-2005)
Specialised in Sports and Nutrition Medicine
One of the best African sprinters in the 1980s 
Still participates in Masters competitions

*Dr. Jim Miller
Family Practice, Sports Medicine
Associate Clinical Professor University of Virginia and Virginia Commonwealth University
FINA Sports Medicine Committee Member
UANA Masters Technical Committee 
Chair, FINA World Sports Medicine Congress 2004
National Team Physician, USA Swimming
President, United States Masters Swimming 2001-2005

Article edited and revised by Dr. Saul Marks, FINA Sports Medicine Committee Honorary Secretary, and by Dr. Margo Mountjoy, FINA Bureau Member (Liaison to the FINA Sports Medicine Committee).

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