This is a good question. The problem is that we don't know for sure. Joe Lindsey, writing for the Escape Collective, said essentially this, that it is normal to want answers, but we simply aren't able to fully explain modern cyclists' performances. As modern sports fans, we just have to live with the uncertainty.
Major advances in sciences explain at least some of the gains. That said, as I argue below, some people are probably doping, even if they're using less than before. Some people likely push the rules with therapeutic use exemptions. I am not sure the sport's institutions are doing all they can to stop meaningful doping.
The basic outline:
- The technological side has advanced a lot.
- Better surveillance = less doping. However, not everyone gets caught.
- People probably act in gray areas, like with therapeutic use exemptions
- There are some institutional factors that should be considered.
The footnotes aren't core to the answer. One of them discusses the first US Department of Justice case against Armstrong that was dropped. Another discusses therapeutic use exemptions for asthma and allergic rhinitis (Wiggins and Froome likely had both conditions and needed systemic corticosteroids). Another mentions a scandal in track and field anti-doping.
The sport's technical side advanced a great deal
Let's get the shortest bit done first: the technical acumen and sports science side has made a lot of progress. Maybe this offsets the incentive to dope. Our knowledge of aerodynamics is a lot better than it was in the 2000s.
Also, sports science has improved a lot since then, meaning that training techniques and our understanding of physiology are better. Power meters are ubiquitous, thus talent can be discovered and trained earlier, in addition to obviously helping with structured training. Also, if it's easier to discover talent, remember that this is likely to increase the overall level of performance by increasing the sheer amount of competition at every level.
Our understanding of nutrition, especially fueling during races, has also changed enormously (they eat much, much more, usually in liquid form). They use altitude camps more aggressively.
You might notice a big differential in performance between the richer and the poorer teams - a lot of these optimizations are very expensive, which would explain that disparity. Of course, there was also a disparity in the doping era. Bigger teams could afford more dope and they organized doping more effectively.
The biological passport means less doping, but does everyone get detected?
The biological passport is a longitudinal monitoring program for blood parameters that could be affected by oxygen doping, implemented by the UCI in 2008. The short version is that it's widely agreed that this has reduced the number of dopers, and if you dope, you have to use less. However, not everyone gets caught. And I worry that the UCI isn't being as vigilant as possible with monitoring athletes.
The UCI can file sanctions using passport data as the sole evidence. The body governing track and field appears to use suspicious passport data to target athletes for surprise testing,5 and I'd assume the UCI also does this. This means dopers can get away with less, which could limit the potential gains to an amount that can be overcome by technical acumen and sports science.
To dispense with the rhetorical question, you can still get away with doping. Here are some illustrative cases. Operation Aderlass in 2019 kicked off when a skier tested positive for EPO and then, under pressure from Austria's law enforcement (not sports authorities) identified others in the doping network. So, every other athlete caught in that operation was doping but was not caught by the biological passport.
In 2010, an internal index of suspicion compiled by the UCI based on biological passport data was leaked to the press. The UCI had elevated concerns about Alberto Contador, Lance Armstrong, and several of their teammates. Contador was caught later that year, but it was for clenbuterol, a bronchodilator that can have fat-burning effects, and not for something more clearly related to blood doping. Although the top 3 suspects were later sanctioned, most suspect riders appear not to have been sanctioned. The UCI could have decided it couldn't meet the burden of proof, but there is a darker possibility I'll discuss under institutional issues. Some less-suspect riders were known to have doped previously, but I'm not sure if they were doping in 2010.
Moreover, Chris Horner was on the infamous list. He later won the 2013 Vuelta with a breakout performance at age 40. Frustrated by the suspicion in the press, he released his biological passport data, because he presumed it would clear him. However, Robin Parisotto, an expert who has examined several biological passports, said that Horner's data had some suspicious patterns that should have led to a follow-up. Unless Parisotto is a crank, the UCI either gave other experts too little data to detect a pattern, or they didn't follow up on the expert findings. During the US Anti Doping Agency (USADA) case against Armstrong around 2012, USADA argued that Armstrong could have been sanctioned using the biological passport in 2010. Interested parties can read the USADA reasoned decision against Armstrong, starting at pg 140. A similar issue occurred with Paula Radcliffe, an elite UK marathon racer, where it initially appeared that some of her biological passport tests were suspicious and hard to naturally explain, and that the appropriate governing body had failed to act. This may not be true. The footnote has more discussion.5
Therefore, from the outside, fans should be at least a bit worried about how well the UCI are making use of the passport data. Fundamentally, sanctions need to be prompt, certain, and fair to maximize compliance (here's an article dealing with this principle applied to probation). Doping sanctions are delayed, and there's a low probability of being caught.
The criminal justice system may be an alternative or a complement. The French seem to be relatively aggressive in this regard, making several raids at recent Tours (with no charges filed). However, in Tyler Hamilton's autobiography, Spain was widely perceived to be lax, and their justice system basically handed out no sanctions from the Operacion Puerto case. If Landis had not filed his suit, the US government was reported to be investigating the case on its own around 2013. However, the case was closed without charges. My read of the situation is that the decision to close may have been related to partisan politics.1
By the way, what would have happened if Armstrong had got Landis a job when he tried to come back into the sport? Basically, the legal system requires initial leverage over someone. Someone has to get caught somewhere. Then they need to confess and implicate others, which is fraught because of the code of silence (omerta). Because that person's credibility may be tainted, law enforcement may need corroborating evidence, which will require more time. The legal system is generally slow, although Operation Aderlass may be an exception.
I hope that anti-doping authorities and law enforcement cooperate, e.g. ADAs pass information on athletes with suspicious biological passports to law enforcement. I'm not aware of reporting that this is happening, and there may be no legal mechanism for direct cooperation.
Methods short of traditional doping
To some extent, there's probably manipulation of grey areas. Here are a few illustrative cases.
Many athletes have asthma or allergic rhinitis diagnoses (lay term for the latter is hay fever, it can cause constriction of your airways like with asthma, aka bronchoconstriction). If you see a primary care doctor for garden-variety asthma, you'll walk out with an albuterol (aka salbutamol in Europe) inhaler. It dilates your airways. 2 puffs is the standard dose. You can take 2 puffs preemptively before exercise. If you need albuterol a few times a week for symptom relief, they add on therapies, usually starting with inhaled corticosteroids. That treatment doesn't cause systemic effects. Modern primary care treatment guidelines typically regard systemic corticosteroids as last resorts.6 They have a higher risk profile than more topical treatments (i.e. inhalers). There are also other systemic alternatives available. Ken Fitch, a sports medicine MD, gave some perspectives (2016, ungated) including anonymized accounts of athletes with severe asthma. Occasionally, even elite athletes have brittle asthma, and have required and got TUEs for ongoing but periodic systemic corticosteroid treatment, generally not prophylactically. He urges athletes to document exacerbations and medication with a diary, which can be evidence if challenged. (NB: I don't have a clinical degree, although I have read the guidelines and I have previously been diagnosed with allergic rhinitis.)
Team Sky sought therapeutic use exemptions for injected or oral corticosteroids for Brad Wiggins three times from 2010 to 2012 for control of serious allergies. As of 2008, Wiggins was on both short- and long-acting beta agonists plus inhaled corticosteroids. As of 2012, his third TUE, he was described as being on "maximal treatment" of inhaled corticosteroids. He may still have had further options short of injected corticosteroids (e.g. allergy shots). He also took the injections prophylactically, which seems unusual. I think the UCI implemented its no needle policy in part because of this incident.
Chris Froome got oral corticosteroids before a race in 2014, although this was a one time deal for a chest infection which reportedly exacerbated his underlying asthma. Had he been stung by an insect, I'd rate this as acceptable use. I'm not sure how I'd rate this application. But both of them may have been within the UCI rules at the time. It may have been standard medical practice for older doctors (e.g. my childhood physician, an older gentleman, prescribed me oral cortisteroids for hives, whereas today we'd have other treatments). There were some procedural issues with Froome's application and perhaps with Wiggins', and today I think it would be multiple doctors reviewing the applications. I don't think the procedural issues were solely Team Sky's fault.
With inhaled short-acting beta agonists (e.g. albuterol for asthma or allergic rhinitis), there is a potential (but small, I think) performance benefit from high doses (much higher than the standard dose). Alberto Salazar, a running coach, reportedly arranged extremely aggressive screening for his athletes, earning him the nickname Albuterol Salazar. That is, an objective observer may not have diagnosed asthma. Additionally, he encouraged misuse of the inhalers. The Norwegian ski team in 2018 also aggressively used albuterol. However, hard exercise in cold weather can cause you to hack up a lung, a symptom which can be confused for asthma - Salazar would get his runners tested after they did a short hard effort and were hacking up said lung. Also, typical medical practice in Norway may have used albuterol in a highly non-specific fashion.
Back to cycling, Chris Froome got caught for having a very high concentration of albuterol. The legal maximum at the time was 16 inhalations; in contrast, 2 inhalations before exercise is typical and accepted, but this is a short-acting substance that wouldn't last a Tour stage. He was diagnosed with asthma. However, as I said earlier, if your asthma symptoms aren't controlled, you should be stepped up in therapy. Moreover, albuterol won't last through a Tour stage, and he would have benefitted from a long-acting bronchodilator. To my memory, he wasn't reported as having used one. If true, that's seemingly a strike against his case. He was able to show that that test could be validly explained, and the sanction was overturned2. However, if he was regularly taking high doses of albuterol per day without using stronger control medications in consultation with a doctor (see footnote 5 for detail), this would appear to be against clinical practice guidelines.
The issue with TUEs is where to draw the line. Froome's and Wiggins' therapies could have been justified, but their team's lack of transparency undercut them. I would judge Salazar's actions as clearly wrong. That said, the performance benefits for grey area stuff are probably small most of the time (I hope). The clearly powerful stuff like EPO, transfusions, and anabolic steroids are straight up banned.
Note that some of these medications can have concerning side effects. We might think of being lenient for things with small or negligible benefits, but the potential harm are worth considering and are a rationale used by WADA. For systemic corticosteroids, prolonged use can cause adrenal insufficiency (meaning that your body's hormone production is impaired). Opioids have been reported to be abused for pain control and performance enhancement. There's the possibility of addiction, and reaction time is reduced (very undesirable in road cycling). Or, say we relax the rules for albuterol. Salazar and his pet doctor will be lurking around every corner with a spirometer and a prescription pad, then he'll tell the riders to inhale more deeply, and then he'll say 2 puffs isn't enough, maybe try 4, then 8, then 16 (former maximum), then maybe more. Albuterol is very safe at standard doses, not Salazar-level doses.
Institutional factors
Institutions are "humanly-devised structures of rules and norms that shape and constrain social behavior." (Wikipedia). For organizational problems, we might consider the incentives that an organization has to act or not to act. This perspective originates from economics, and most people going into public policy-related degrees will have at least one economics course. Here are some issues that I think stem from the incentives that anti-doping agencies face.
Say there's a big scandal and a lot of people come forward, some of them even come willingly, and some of the major cases get drummed out of the sport. Then, say you come in after the scandal and you want to start a completely clean team, as Team Sky initially said they wanted. Without meaning to absolve the team over its later lack of transparency, you probably won't have enough people who are squeaky clean and who also have the expertise you want. It's not just the riders, it's the doctors, managers, soigneurs, etc. If you take on tainted staff, then if someone decides to dope, the institutional knowledge is there, and you have people who don't necessarily think it's wrong. Or you run the risk that some of them start to groom younger riders into accepting things they shouldn't. Tyler Hamilton described team doctors essentially doing this (e.g. start vitamin injections and titrate upwards the number of not-quite-on-the-level things). When he actively decided to dope, the gap between values and actions was smaller.
Second, there's potentially a perverse incentive for anti-doping regulators not to look too hard. I feel like you can clearly see it in the biological passport cases I described above. After all, if you're the UCI and you catch a bunch of athletes, you now look bad. Other sports are likely being less vigilant than cycling, like perhaps baseball and football in the US. Do you really want to look worse than them and attract public scrutiny that they aren't getting? If you proceeded aggressively, you might have honor, but you can't eat honor and the sport can't be funded by honor, and a lot of stakeholders would complain, so ...
This perverse incentive could manifest as Hein Verbruggen3 gathering key UCI staff in a smoke-filled room4 and explicitly saying "bury Lance Armstrong's positive test." He is alleged to have done exactly this, by the way. But more likely the institution and its managers could just take a course that produces that result. For example, the UCI staff could have decided to make the threshold for action on the biological passport higher than a more aggressive regulator might want. They almost surely have facially valid reasons, e.g. we want to reduce false positives, because those would undermine confidence in the system. If some crusader later comes in, the bureaucracy would give them an earful of those facially valid reasons, or maybe they aren't staffed for this, where do I get the staff, etc, then the changes take a long time, then maybe the idealist decides it isn't worth it, or maybe they get replaced. You'd hope law enforcement doesn't experience this, but see the first footnote for one case where they may have.
Here's another way this perverse incentive might manifest. It may seem contradictory to the above, but bear with me. The majority of anti-doping cases are for very low doses of prohibited substances. The legal standard is that the athlete is strictly liable for anything found in their body. However, the labs have been getting much more sensitive to small amounts. Say you catch an athlete with a few nanograms of a diuretic (masking agent). You'd win the case if you brought it. But if it were a false positive, the sport would be worse of. But perversely, nobody would be able to prove this. The athlete would complain bitterly but who'd believe them? You're catching enough people to convince everyone that you're doing your job ... although heaven forbid that you catch one of the star athletes. With Froome's albuterol case, the UCI initially closed the case, and they shielded it from public view for several months (the news was leaked). They were perceived as not being impartial and transparent.
If I had carte blanche, I would instead target that athlete for surprise at home tests, unannounced tests at lower-tier races, whatever other options exist. If I catch them in flagrante delicto, then I offer leniency to implicate a supplier or doctor. However, this is more work, and doping tests are expensive.
Third, all institutions have inertia. That is, even if it's a non-democratic institution and the CEO says to do something, the decision has to promulgate downward through layers like middle management, so things take time. If it's doing something easy like not looking, then there's probably less inertia. But if it's doing something potentially costly or that requires active effort, then delay or possibly outright resistance at every level of management adds time. If it's a democratic institution, you may have to get key decision-makers to agree before you can act, adding more time.
For an example, the World Anti-Doping Agency banned tramadol (an opioid) in competition in January 2024. The UCI banned it in for cycling 2019 (from 2019-2024, its use would only lead to annulment of results, like Nairo Quintana in the 2022 Tour).
But there were rumors of tramadol or other opioid use going back to at least 2012. In 2016, then-UCI President Brian Cookson said that the UCI understood clearly that it was being abused. Presumably the UCI got their first warning earlier than that. Yet they took 3 years after that 2016 statement to prohibit it, and then WADA lagged them by an additional 5 years. In contrast, the Movement for Credible Cycling (French acronym MPCC) prohibited member teams from using tramadol in 2013. WADA is the global-level anti-doping agency, and it doesn't directly run the sports it oversees, so it also shouldn't have faced the perverse incentive described earlier, whereas the MPCC would have been directly harmed. Thus, I feel that institutional inertia is a separate factor from perverse incentives. I'd expect institutional inertia to increase the response time, whereas the perverse incentive above decreases the level of surveillance.
The UCI both organizes the sport and is the anti-doping regulator. I believe it's not typical of other sports. This is a conflict of interest.
Last, leaks happen because someone inside an organization decided to covertly give information to a reporter. Going back to the two leaks I mentioned above, one or more people in the UCI and also in the IAAF (governs track and field) made an active decision that would jeopardize their careers if they were uncovered. I think that they most likely felt like their regulatory bodies were failing in some way.
Footnotes
Some reporting is here, and Tyler Hamilton's autobiography also mentions this case. There was a Federal case against Armstrong in 2013 that had made some progress, but the US Attorney in Los Angeles dropped the case. No explanation was given. Given the political situation at the time, with Armstrong still regarded as a hero, it would have been very controversial and would have caused political trouble for the (Democratic) Obama administration. By established norms, the US Department of Justice is supposed to be independent of the President. Nevertheless, my assessment is that the Republican Party would have politicized the case if it were brought to trial, which likely provided incentive to close it. There is no proof of what the US Attorney was thinking, however.
As with a host of biological and physical parameters, some metabolize or excrete drugs slower or faster than average, sometimes by a lot. Froome essentially showed that a combination of dehydration and individual variation in pharmacokinetics could explain his reading.
Verbruggen ran the UCI from 1991 to 2005. He's widely suspected of protecting Lance Armstrong, generally tolerating doping, and also of other forms of corruption. My view is that he was terrible, and even if the next two presidents weren't saints, they almost had to be better than him probabilistically.
This is US political jargon, referring to an inner circle of unaccountable power brokers gathering in closed session. The term originated when tobacco use was the norm, hence the reference to smoke. The phrase Star Chamber has some of the same connotations.
I'm not as familiar with the specifics. However, around 2015, someone leaked biological passport data for a large number of athlete profiles held by the International Amateur Athletic Federation (IAAF), which governs track and field. Radcliffe had three of her samples deemed potentially suspicious, but not definitely indicative of doping. That is, the 3 results could have been explained by external factors like dehydration. Radcliffe refused to release her full data set, which could have settled her claim, but she chose not to, feeling like she was being subject to a witch hunt. That is, her full set of individual data could better establish that the 3 suspected readings were not anomalous in the context of her own individual variation - remember that biological parameters can vary by quite a lot.
The IAAF made an initial response to Michael Ashenden and Robin Parisotto, the two scientists who looked at the passport readings. Ashenden and Parisotto were not satisfied. A later World Anti-Doping Agency (WADA) investigation found that IAAF experts were in fact taking action, although they sometimes had to fight their superiors to do so. Ashenden declared that based on this, the IAAF deserved the benefit of the doubt going forward.
The American Academy of Family Physicians (AAFP) is one of the bodies representing primary care doctors/general practitioners in the US. Here is a summary of their clinical practice guidelines for allergic rhinitis (hay fever is the lay term for seasonal allergic rhinitis), and here is the full version in the journal Otolaryngology (free to access, I believe). This is the AAFP guideline for asthma. Asthma and allergic rhinitis are distinct but related. Allergic rhinitis can cause asthma symptoms. Asthma can be caused by allergies or a host of other things. Remember these are guidelines, not algorithms. It would be stupid to forbid expert judgment.
I suspect Wiggins had both diagnoses based on public statements. The Fancy Bears hacking group leaked the first pages of his TUEs. It refers to wheezing and shortness of breath, plus sneezing, runny nose, and eye watering.
Under the asthma guidelines, you would start with basic treatments, then titrate the therapy upwards until asthma is controlled. If the patient went into the emergency room, this isn't necessarily the case. Anyway, step 5, the maximum, says (emphasis mine)
Patients with persistent and severe symptoms despite optimal use of step 4 treatments should be referred for allergist evaluation and consideration of add-on treatments ... includ[ing] high-dose inhaled corticosteroids and long-acting beta agonists, tiotropium (Spiriva), azithromycin (Zithromax), anti-immunoglobulin E, anti-interleukin-5/5R, anti-interleukin-4R alpha, sputum-guided treatment, bronchial thermoplasty, and low-dose oral corticosteroids. Adverse effects and the risk of antibiotic resistance should be taken into account when considering these treatments.
I believe the medications with funny names are generally non-steroidal injectable drugs that modify or suppress the body's allergic response. Note how low-dose oral corticosteroids are the last mentioned option.
Recall that Wiggins used intramuscular corticosteroids, but I'm not sure how the dosing compares to oral cotricosteroids. I believe some patients and possibly MDs on Reddit attested that intramuscular or oral corticosteroids may have been accepted practice in the UK and elsewhere. Some of this is memorialized in this Reddit post. I am the author. However, I maintain that it's a problem in the sporting context that Wiggins' treatment appears to deviate considerably from guidelines.
Wiggins appeared to argue that he was a world-class athlete with severe asthma during allergy season. Severe means that high levels of therapy are required to control asthma. This may seem incompatible with being a world-class athlete, but it is backwards to write athletes off if they need reasonable medical treatment to compete. The sports doctor cited earlier seems has a case study of an athlete who needed oral corticosteroids to manage asthma exacerbations. However, Sky's defensiveness and lack of transparency lost them some goodwill. I am also not certain if we should take Wiggins' statements at face value, although inconsistency in his previous performances is consistent with asthma.
You can find the two Wiggins TUEs on the Internet Archive. Fancy Bear hosted them on their own site, which is now down. Here's the first and here's the second.
