Part 1: The introduction of blood doping The recent revelations by the Dutch newspaper De Volksrant concerning the PDM team's doping regime at the 1988 Tour de France raise more questions than they answer, particularly with regard to the use of blood transfusions in 1980s cycling. Here we consider what is known about the use of transfusions in general and some of the questions these latest PDM revelations raise in relation to the history of blood doping in cycling. Part I What is known about the use of blood transfusions in sport, particularly in cycling? Most people will be able to tell you that the Finnish middle-distance runner Lasse Virén is said to have made use of transfusions when winning at the Munich and Montreal Olympics in 1972 and 1976. Most people will also be able to tell you that Francesco Moser broke Eddy Merckx's Hour Record in 1984 with the help of blood transfusions. And most people will be able to tell you about the US cycling squad at the Los Angeles Olympics later in 1984 and how they ended a seventy-two year medal drought, again with the aid of blood transfusions. After that, the use of blood transfusions disappears from most people's knowledge until after the arrival in 2000 and 2001 of tests for EPO, at which point the clock is said to have been wound back and the accumulated knowledge of blood transfusions taken out of cold storage and applied to modern cycling. The revelations in the Operacion Puerto papers (2006 onwards), the Freiburg Report (2009) and the recent USADA report (2012) have all widened our knowledge of how blood transfusions were utilised in cycling in the early years of the new century. The years before, though, are still shrouded in darkness. The first scientific studies to highlight the possible sporting benefits of transfusions appeared after the end of the Second World War. These studies were not aimed actually at sportsmen but came out of the military and were aimed at ways of combating hypoxia. In 1945, Pace et al published their first paper The Effect of Transfusions of Red Blood Cells on the Hypoxia Tolerance of Normal Men which was followed by another in 1947, The Increase in Hypoxia Tolerance of Normal Men Accompanying the Polycythemia Induced by Transfusion. In both studies Pace and his team were able to demonstrate a significant increase in endurance post-transfusion. The next major study on the beneficial effects of transfusions came in 1960 when Gullbring et al published their paper The Effect of Blood Volume Variations on the Pulse Ratio in Supine and Upright Positions and During Exercise. This was based on the transfusion of 610ml blood one week after extraction. In 1966 Robinson et al published another paper, Circulatory Effects of Acute Expansion of Blood Volume based on a study transfusing 1,000ml of blood two weeks after extraction. Both Gullbring and Robinson's studies showed only marginal post-transfusion gains – two to three per cent – in endurance or VO2 max. On the horizon, though, were the 1968 Mexico Olympics, and they were about to put fire to the fuse of many who would seek to emulate the effects of altitude artificially. The breakthrough study came in 1972, a paper published by Björn Ekblom and two of his colleagues at the Institute of Physiology of Performance in Stockholm, Responses to Exercise After Blood Loss and Reinfusion. Ekblom and his colleagues noted a 16-25% increase in the stamina of subjects who had been transfused with 800-1,200ml of blood four weeks after extraction. The developments of the 1970s As the 1970s progressed competing scientific papers appeared, each offering diverging – and often contradictory – views on the effectiveness of transfusions in a sporting environment. In the UK, JPG Williams and PN Sperryn published a book in 1976, Sports Medicine, in which they poured cold water on the procedure: "Experimental re-transfusion of subjects with their own red cells after an interval of four weeks was thought to give improved performance, but this has subsequently been denied by further studies. In view of the dangers inherent in the whole process of blood transfusions, it is unlikely that further developments can be expected." But developments were made. The flaws in the procedure – particularly with regard to identifying the optimal amount of blood to extract and re-infuse, and identifying the correct period which should elapse between the two procedures – were ironed out and the effectiveness of blood transfusions was recognised throughout the sporting and medical communities. The doping arms race stepped up a gear. Quite when the sporting world recognised the effectiveness of transfusions is open to debate. Various papers on the subject claim that as early as the 1930s Scandinavian runners were benefiting from transfusions, but no details are given, specifically with regard to the identities of the athletes involved or the nature of the transfusions. Let's say that there's a degree of doubt over this claim. Without details, we have to question how advanced the process could have been in the 1930s, with kinks in the proper use of anticoagulants and even blood typing still to be ironed out. Enter cycling with Nencini and Anquetil More concrete claims are made about the use of transfusions in the 1960s. Cycling gets the credit for the next instance of their alleged use. Many papers on the subject claim, often with a degree of authority, that Gastone Nencini benefited from a transfusion while on his way to winning the 1960 Tour de France. The story here starts with a quote from the Tour's doctor, Pierre Dumas, an early leader of the fight against doping. Dumas is said to have entered Nencini's hotel room one evening during the Tour and seen the Italian propped up on his bed, a cigarette in his mouth and drip in each arm. As if that alone were not a wonderful enough picture, somewhere along the way a bag of blood has been painted in and a modern myth has been created. And, like the much misreported death of Arthur Linton, this story has gathered a life of its own and is repeated time and time again. There was, though, no bag of blood and there is thus no reason to believe that Nencini was blood doping as early as 1960.
Gastone Nencini wins the 1960 Tour de France. Photo: AFP The next case also involves cycling and is credited to Jacques Anquetil, who was, as we all know, a vocal defender of the rider's right to medicate. While Anquetil did engage in a form of blood manipulation, it would probably be incorrect to refer to it as a transfusion. What he was actually playing with was super-ozone therapy, whereby a small amount of blood is extracted, treated with ozone and immediately re-injected. The ozone is said to increase the amount of oxygen carried in the blood. Some people believe it does. Others believe it's baloney. That Anquetil was using this treatment is no secret, Pierre Chany, in a couple of articles in Miroir des Sports during 1967, wrote about it, and how Anquetil had used the treatment during the Giro d'Italia and intended using it during his assault on the Hour record later that year. A doctor, Jean Bidet, had written to Anquetil's directeur, Raphaël Géminiani, and explained the process. Gem was intrigued enough to find out more and, after using himself, Anquetil and Jean Stablinski as guinea pigs, was able to convince Maître Jacques of the benefits of the procedure. So, each day during the Giro, before and after each stage, Anquetil had an injection of ozone-treated blood. It didn't help him win the 1967 corsa rosa: Felice Gimondi and Franco Balmamion finished ahead of him. And, while Anquetil did set a new distance for the hour later in the year, the UCI refused to recognise the record following Anquetil's refusal to submit himself to dope control. Blood doping at the Olympic Games So far we're nought-for-three on the use of transfusions in this story. Whether we go nought-for-four is something you will have to decide for yourself, for the next character in this supposed rogues' gallery is Lasse Virén. At the 1972 Olympics in Munich, Virén, a Finn, won gold in the 5,000 and 10,000 metre athletics events. Some at the time thought there was something odd about Virén's victories. He seemed to have come from nowhere and was now winning on athletics' biggest stage, even after having stumbled and lost thirty metres in the 10,000. Questions were asked. A 1973 issue of Áthlesime magazine claims that an American journalist, Don Steffens, in a press conference after the 10,000m race asked Virén directly if he had used transfusions. At first Virén is said to have replied in the negative, but when pressed again by Steffens said yes. Virén is also said to have claimed that the secret of his success was reindeer milk, so he may just have been yanking Steffens' chain. Over the next four years the scientific community got into heated debate about the effectiveness of transfusions. Come the Montreal Games it wasn't scientists asking the questions, nor was it a lone journalist: blood doping became one of the stories of the 1976 Olympics. It's important to stress at this point that, in the 1970s, blood doping was not illegal, not under the IOC's code, nor under the codes of any of the major sporting bodies. The fight against drugs in sport was barely a decade old at this stage, amphetamines and steroids were believed to the real enemy. Blood doping was the appliance of science, cutting edge stuff. And yet, despite this, media and fans alike considered it morally questionable, and athletes preferred not to talk about it. Imagine that for a moment, a world where athletes could boast about the powers of reindeer milk and yet be afraid to openly discuss the appliance of cutting-edge science. So what happened at the 1976 Games to make people ask questions about blood doping? Well first of all there were the Soviets and their allied states, who were racking up points on the medal table like they were playing pinball. The Olympics were just an extension of the Cold War, and East and West went at it to prove the superiority of each system. Back then every Soviet success was questioned and attributed to doping, and the Soviets were always assumed to have the latest and the greatest weapons in the doping armoury. Blood transfusions being the flavour of the hour, that was naturally assumed to be the secret of their success in 1976. Sometimes the speculation about the secret of Soviet successes was well placed, sometimes they were ahead of the game with products. But other times they were just better at the game than others. For instance, Soviet athletes avoided positives by being tested ahead of competition and pulled if they were likely to get caught. But sometimes the Soviets really were ahead of the game with products. Creatine, for instance, was in use in the Soviet bloc a good decade and more ahead of the West. And complementing the use of creatine in anaerobic sports the Soviets were on top of the use of transfusions in aerobic competitions. Evidence discovered by Michael Kalinski in State-Sponsored Research on Creatine Supplements and Blood Doping in Elite Soviet Sport showed that blood transfusions were a major weapon in the Soviet's doping armoury at the Montreal Games. Bit it wasn't just the Soviets. The Finns were putting on an impressive show too, and star of the hour was that man again, Lasse Virén. In the four years between Munich and Montreal Virén had underperformed, on the few occasions when he had deigned to perform. But cometh the hour, cometh the man, and in the Olympics the Finn again won gold in the 5,000m and again doubled it with the 10,000m, on this occasion with a new world record time. The cynics and the sceptics in the audience scoffed and said blood doping. Those who dared to believe in miracles pointed to Virén's big engine and noted that, while others raced to train, Virén had trained to race, sequestering himself at altitude camps where he put in efforts unseen by the world's media. And this is true about Virén, his training techniques did help to overturn the conventional thinking in athletics. But was their blood doping involved as well? This time when Virén was asked the question he was emphatic in his denials. However, that there was blood doping going on in the Finnish camp is now pretty well established. A teammate, Kaarlo Maaninka, confessed in the early 1980s that he had used transfusions during the 1970s. Virén, though, his story has never changed: he never used transfusions. It's up to you what you want to believe, whether you want to believe in big engines and intelligent training or whether you want to believe in blood doping. Beckenbauer and soccer What is really known about blood doping in the 1970s then? Well, in 1977 Franz Beckenbauer, captain of West Germany's 1974 World Cup winning squad and of the European champions, Bayern Munich, confessed to using a form of blood manipulation. "I have a particular method for remaining at the top level: the injection of my own blood," he told the magazine Stern. "So, several times a month, my friend Manfrid Köhnlechner takes blood from my arm and injects the same blood into my buttocks. The number of white blood cells, and especially the number of red blood cells then multiplies and the forces of resistance are thus mobilised in the body." I'm not sure I'd go so far as to call that a transfusion, not in the sense that we understand the word, but it is a form of blood manipulation. Or, like Anquetil's ozone treatment, a form of quackery. So where was cycling at this stage of the game? Nencini we've nixed, Anquetil we've poured cold water on. Was there even one cyclist using a real transfusion? Well yes, there was. In 1977 Joop Zoetemelk confessed that, during the previous years' Tour, when he was a member of Raymond Poulidor's Gan-Mercier team, he had undergone transfusions on the advice of his doctor, Henri Fucs. Zoetemelk's 1976 Tour saw him winning a couple of stages in the Alps – including Alpe d'Huez – as well as the stage to the Puy de Dôme and overall he finished second, four minutes something down on the winner, Lucien van Impe.

Joop Zoetemelk in the 1979 Tour de France. Photo: AFP Zoetemelk had crashed out of the 1974 Midi-Libre race and since then had been suffering from anaemia. As a way of ameliorating the effects of Zoetemelk's anaemia, in 1976 his doctor, Henri Fucs, prescribed transfusions of red blood cells. By the following year's Tour Zoetemelk's anaemia was cured and, before the 1977 race, at the pre-Tour medical control, he declared he wouldn't be using transfusions again. In essence Zoetemelk – who was something of a repeat offender when it came to getting busted by the dope controllers, particularly at the Tour (1977, 1978, 1979 and 1983) – was saying that his transfusions were not performance enhancing but were merely therapeutic and properly prescribed by a competent practitioner. He was just re-balancing his system. That, more or less, is the story of blood doping in the 1970s. A lot of speculation – some well founded, some not so well – and a few confessions that don't really shock. Through the eighties the veil of secrecy surrounding the use of transfusions would be pushed aside and we would learn a lot, lot more about their use. 


A history on blood transfusions in cycling, part 2 By: Feargal Mc Kay Transfusions peak in the 1980s before EPO appears The recent revelations by the Dutch newspaper De Volksrant concerning the PDM team's doping regime at the 1988 Tour de France raise more questions than they answer, particularly with regard to the use of blood transfusions in 1980s cycling. Here we consider what is known about the use of transfusions in general and some of the questions these latest PDM revelations raise in relation to the history of blood doping in cycling. Part II In the first part of this series looking at the history of blood transfusions in cycling we've taken the story up to the end of the 1970s. In this part we look directly at the 1980s. After the 1977 confession from Joop Zoetemelk transfusions don't appear again in the known history of cycling until 1984 when, in January of that year, Francesco Moser beat Eddy Merckx's 1972 Hour Record, twice in the space of five days. Everything about Moser's Hour screamed proper preparation, a real scientific assault on the record. Like Merckx's record a dozen years earlier it was set at altitude, but in most other regards Moser and Merckx were playing by different rules. Moser made his assault on the record in January, after months of preparation whereas Merckx – and other Hour men generally – rode at the end of a long season on the road. Moser's bike was state of the art and – somewhat counter-intuitively – heavier than the machine Merckx rode on. Conconi enters Today, most all the credit for the 1,720 metres Moser added to Merckx's record over the two rides is given to the scientists who worked with him: Francesco Conconi of the University of Ferrara's Centre for Biomechanical Studies, and his assistants, principally his protégé Michele Ferrari and the man who would go to be the Good Witch of the North to Ferrari's Wicked Witch of the West, Aldo Sassi. Conconi's principle contribution – his area of speciality – was in identifying Moser's lactate threshold, the limit of exertion the aging Italian star could ride at without producing more lactic acid than his muscles could deal with. This Conconi was able to boost by the use of blood doping, a fact Moser finally confirmed in 1999, after the Festina affaire caused the skeletons in cycling's cupboard to be rattled. "I was not the only one nor the first who used blood transfusions to improve my performance. I was told that Jacques Anquetil had done it and that was well before my time. […] It was my own blood. And I was not the only rider doing it," Moser told L'Equipe. (For the record, one journalist – Joël Godaert – claims that Merckx was offered a transfusion for his 1972 assault on the Hour but declined.) Quite when Conconi began working with blood transfusions is not clear. What is known is that in the early 1980s the Italian athletics federation, with the support of the Italian Olympic committee (CONI) had put Conconi in overall charge of the preparation of their athletes ahead of the Los Angeles Games in 1984. And that doping – with both drugs and blood – was part of Conconi's armory. This fact is known because another Italian coach, Sandro Donati, publicly complained about the practices employed by Conconi and his staff at the Ferrara institute, particularly the use of blood doping, Donati was appointed coach of Italy's 800 and 1,500 metre male runners in 1981 and shortly after his appointment was introduced to Conconi. When Conconi explained some of his procedures to Donati, particularly the manner in which he had refined the Finnish experience with blood transfusions, Donati took this as proof that some of Italy's successes at the Moscow Games in 1980 had been achieved with the aid of blood doping. A man of principle and something of a puritan when it comes to doping, Donati was not interested in such procedures. When he and his athletes refused to work with Conconi, Donati was informed that his position as national coach would be terminated after the 1984 Games. Conconi remained in situ and transfusions remained part of the Italians' armory in preparing for Los Angeles. Donati, though, was not a man for taking defeat lying down and, finding his complaints ignored by CONI – who had the dual mandate of both policing and promoting Italy's Olympic efforts – took his case to parliament. There he met with a politician who was also a haematologist, Andrea Ceci. In 1985 a question was tabled in the Italian parliament, asking the health minister to state whether or not blood transfusions were against the rules. Again, you have to remember, that the procedure was not yet specifically banned in sport. In fact, the IOC had been petitioned to ban transfusions after the 1976 Games but their medical commission – led by redoubtable Prince Alexander de Mérode – refused, on the basis that it was impossible to test for transfusions. When faced with a parliamentary question from Ceci, the Italian health minister didn't care whether transfusions could be tested for or not. They were declared illegal under Italian law. The US team in 1984 The Italians were, it goes without saying, not alone in turning to blood transfusions to boost their performances at the Los Angles Olympiad. The Soviets not being in attendance, no accusations could be levelled at their door this time. But they could be levelled at the door of the host nation. Specifically, the door of the US cycling team. Cycling in the US in the early 1980s was a minority interest sport. But it was getting more and more lucrative. Jim Ochowicz and George Taylor had been able to secure the support of the 7-Eleven chain of convenience stores to sponsor a team of cyclists led by the former champion speed skater, Eric Heiden. 7-Eleven were already funding the construction of the vélodrome for the Los Angeles Games, and Taylor and Ochowicz had sold them on the idea of sponsoring their team by saying 7-Eleven could effectively own cycling in the US. By the time the 1984 Games came around 7-Eleven riders – male and female, track and road – filled nine of the twenty-three seats in the cycling squad. The American cyclists had a great Games. A medal drought dating back to 1912 was ended in spectacular fashion, with the cycling squad bringing home nine medals, four of them gold. Blood doping wasn't the sole cause – the Americans were helped by the absence of the Soviet riders and by the presence of some pretty good riders – but blood transfusions did play a role in some of the successes: five of the squad's medallists, along with three others, confessed to having used transfusions. When this was made public, months after the Games ended, all the medals won were tainted by the stain of blood. The US blood doping programme began life in 1983 when Ed Burke, who held a PhD in physiology and was technical director to the cycling squad, first floated the idea of the US cyclists making use of transfusions. The US Olympic committee, USOC, told Burke he could go ahead but only if the cycling federation were willing to give the project the green light. So Burke took his proposal to the USCF, who stalled on the subject, saying neither yay nor nay. Burke's plan went into the bottom drawer. Ahead of the Games one rider who was seeking to gain selection, Danny van Haute, underwent a transfusion under his own initiative (there had been talk among the squad of Burke's shelved plan). Van Haute here had the advantage of having a father who was a medical doctor. His performance in the trials won him selection. And served to encourage other riders to want to make use of transfusions at the Games themselves. At which stage the coaching team intervened. Not to discourage the use of transfusions. But – they claimed – to make sure they were done properly and safely. Not all the riders underwent the procedure. One who refused was Connie Carpenter – the mother of Taylor Phinney – who opened the Games with gold in the women's road race. As far as she was concerned, it was the coaching staff who were responsible for allowing transfusions to become part of the squad's preparation: "It's real bad for cycling, and it's real bad for all of us who didn't participate: The blame falls directly on the coaching staff, and from everything I've heard since, I'm surprised nobody died," she told Sports Illustrated. The key coaching staff involved here were Burke, federation vice president Mike Fraysse and coach Eddie Borysewicz. There being insufficient time to extract blood for reinfusion they decided to use blood from compatible donors among the riders' friends and families (heterologous transfusions). Nor was there time to spin out the red blood cells, so the transfusions were of whole blood. A cardiologist from the University of Iowa – Herman Falsetti – was brought in to carry out the transfusions, which were performed in the comfort and safety of a Ramada Inn. There are several different versions of how the US cycling squad's blood doping came to the attention of USOC and USCF after the Games had ended. Who said what to whom and why is unimportant here. What matters is that in January 1985 Rolling Stone got hold of the story. In an effort to spike Rolling Stone's guns and control the news cycle other media outlets – press, magazines and TV – were fed versions of the story. But no amount of spinning was going to deflect this story and – regardless of the fact that transfusions were not banned – the sheen was very quickly and very publicly taken off the cycling squad's successes. Between the US Olympic squad and Moser's Hour rides, 1984 proved to be something of a watershed year for the use of blood transfusions in cycling. But there was more going on that just those two cases. New evidence has recently come to light which suggests that transfusions also became part of the doping armory in the Continental peloton. Interviewed by Daniel Friebe for his Eddy Merckx biography, The Cannibal, Roger de Vlaeminck made reference to the use of blood transfusions when he was a member of Moser's 1984 Gis-Tuc Lu squad. "They spoke to me about blood transfusions." De Vlaeminck told Friebe. "When I was riding for Francesco Moser, they asked whether I wanted to give half a litre of blood to put in the fridge. I said no…" Dr Ferrari That the Gis squad may have made use of blood transfusions in 1984 is hardly a surprise. We know that Moser had used transfusions to set the Hour record in January, he did eventually confess to this fact, in 1999. Whether the Italian used the procedure at other times, especially in the Indian Summer of his career in 1984 when he won Milan-Sanremo and the Giro d'Italia, remains unknown. Part of the reason suspicion surrounds these victories is that it seems crazy to imagine that transfusions, their effectiveness having been proven, wouldn't have been used again and again and again. Another part of the reason is that, in 1984, Michele Ferrari started working with Moser's Gis team. Ferrari was on the staff at the University of Ferrara and part of the team Francesco Conconi had assembled to prepare Moser for the Hour. In 1984 Ferrari was moonlighting with Moser's squad, splitting his time between Ferrara and Gis. For the 1985 season he went full time with the team. In 1986 Moser switched squads and joined Gianluigi Stanga's Supermacati outfit and Ferrari went with him. Ferrari stayed with Stanga through to 1989, by which time the team had become Château d'Ax. It was there that he first hooked up with Toni Rominger, who hired him as his personal coach after Ferrari had quit Château d'Ax and hooked up with Moreno Argentin. Working with Argentin, Ferrari became a part of Giancarlo Ferretti's Ariostea squad, briefly working alongside Luigi Cecchini. That, as we all know, lasted through to 1994, by which time the team had become Gewiss, and Ferrari made his infamous orange juice comment. After that, Ferrari went into private practice, hanging a shingle on his porch and waiting for rider's to come to him. Rominger setting a new Hour record toward the end of the 1994 season acted as an advertisement for Ferrari's abilities, especially with Rominger doing a Moser, first beating the record by 792 metres and then coming back two weeks later to stuff another 1,459 metres onto the distance. Apart from that one reference by De Vlaeminck to the use of blood transfusions at Gis in 1984, there is no evidence that transfusions continued to be used at the team beyond that one season. There is no proof that transfusions were used at Supermacati, or at Château d'Ax, or at Ariostea. We can say, with some degree of confidence, that Ferrari is suspected of having advanced to EPO by the time the 1994 Gewiss squad started to strut their stuff. But we don't know anything about the use of transfusions. Not in the teams Ferrari worked with between 1984 and 1994, nor in any other teams in the professional peloton. In fact, up until the recent PDM revelations, there is no evidence at all of transfusions having been used in cycling after 1984, not until their reappearance a decade and a half later. So what happened after 1984 to make blood transfusions fade away? First up, there was the IOC finally moving to ban the procedure. In 1985 those who had tried to get the IOC to ban the use of transfusions after 1976 renewed their efforts and, with the scandal in the US raging, Sandro Donati kicking up a rumpus in Italy and a number of other athletes having confessed to having used the procedure, the IOC was backed into a corner. Transfusions were added to the banned list from 1986 onwards. That, of course, is insufficient reason for blood transfusions to disappear. From the case of the US Nordic skier Kerry Lynch – who was busted for blood doping after someone spilled the beans on what he and a couple of US coaches were up to – we know that transfusions were still being used in the wider world of sport as late as 1987. And, from the revelations in the Dutch daily De Volksrant, we now have evidence that they were part of the armory in the PDM squad in 1988 (these claims we'll consider in greater detail in the final part of this series). By the end of the 1980s, transfusions are thought to have fallen out of favour. There was talking of developing a test to detect them – Bo Berglund published a paper, Detection of autologous blood transfusions in cross-country skiers, in which he proposed a form of indirect detection based on the difference between two samples taken a week apart – but that isn't what is supposed to have drawn the curtain closed on the use of blood transfusions. No, they're supposed to have fallen out of favour because they were superceded by the new thing: EPO. Quite when this happened is not clear, different people will give you different dates anywhere between 1987 and 1992. It is clear that, at the Winter Olympics in Calgary in 1988 the existence of EPO was already being discussed openly. It is clear that as early as 1988 scientific papers were being published trumpeting the beneficial effects of EPO in the sporting community. It is clear that as early as 1988 the international Ski federation banned its use (the IOC waited until 1990, the UCI 1991). And what is also clear is that as early as 1988 bodies were beginning to pile up on mortuary slabs as athletes in several sports began to experiment with EPO and die in their sleep. Gen-EPO was taking its first, faltering steps. On a simple cost/benefit comparison EPO trounced transfusions, made them redundant. Though expensive in the early years EPO's price quickly fell. But even above the cost, EPO was logistically less complicated than transfusions, vials of EPO could be transported in ice-packed thermos flasks. There was simply no reason to engage in the hassle of expensive transfusions. Until, that is, tests for EPO came along in 2000/2001. At which stage transfusions – which were still undetectable – once more became part of the doping armory. Evidence, though, suggests that transfusions did not go away. Evidence suggests that transfusions remained part of the armory, at least for some

PDM and the 1988 Tour de France The recent revelations by the Dutch newspaper De Volksrant concerning the PDM team's doping regime at the 1988 Tour de France raise more questions than they answer, particularly with regard to the use of blood transfusions in 1980s cycling. Here we consider what is known about the use of transfusions in general and some of the questions these latest PDM revelations raise in relation to the history of blood doping in cycling. 
Part III The possible sporting benefits of blood transfusions have been public knowledge since the 1940s. Through the 1950s little seems to have occurred on this front but by the 1960s more and more people were interested in ways to manipulate athletes' blood. As we saw in the first part of this series, the 1970s are thought to have seen transfusions come to the fore, though few names have been definitively linked to the procedure. In the second part we considered the 1980s, particularly the watershed year of 1984, and the IOC's banning of transfusions, which up to then had been wholly legal. Conventional wisdom has it that, shortly thereafter, transfusions fell out of favour in the sporting world, having been superseded by the use of EPO and didn't come back into vogue until the early years of the new millennium. Recent revelations, though, suggest they came back into vogue a lot earlier than people thought. Before considering how little we know about the use of blood transfusions in 1990s cycling, let's return to the 1980s and consider how little we really know about their use in that decade. Most all the early evidence we have for the use of blood transfusions in cycling dates to 1984: Francisco Moser's Hour record, the US Olympic cycling team and, most recently, the suggestion by Roger de Vlaeminck that transfusions were in use at Moser's Gis squad. Beyond that, you will be hard pressed to find evidence of the use of transfusions in cycling in those years. Until, that is, the recent revelations about the 1988 PDM Tour de France squad. The Dutch daily De Volksrant's revelations about doping at PDM in 1988 are just the latest in a long line of stories about what happened at that team. That PDM doped is like the Pope's religion, something everybody knows. The team's name – Philips Dupont Magnetics – has been recast in multiple languages. In Dutch it's become Prestaties Door Manipulaties (performances through manipulation). In French it's Plein de Manipulation (full of manipulation). Pills, Drugs and Medicine is how the English-speakers say it. For some it may seem odd that none of the previous PDM inquiries have uncovered the use by the team of blood transfusions. Or that none of the PDM riders who have confessed to doping during their time in the peloton have mentioned the use of transfusions. That previous investigations made no mention of transfusions may simply be down to their scope. Those investigations come from the 1990s. The main PDM investigation was actually into tax evasion by a pharmacist who was supplying drugs to the team. Transfusions may simply not have arisen as a topic of inquiry. That former PDM riders haven't mentioned their use of transfusions is harder to explain, other than to say that few riders ever seem to confess everything. Gert-Jan Theunisse, for instance, has confessed to having used other drugs during his career but denies ever having used testosterone, despite having failed several tests for the substance. The lack of other evidence to support the use of transfusions by PDM may mean that the team only briefly dabbled with the procedure. Or it may be that De Volksrant's revelations about the use of transfusions should be taken with a pinch of salt, or at least held in reserve until more pieces of the jigsaw appear. Quite frankly, right now we don't know. So what do we know about PDM's use of blood transfusions in the 1988 Tour? Based on what was revealed by De Volksrant we know that PDM are said to have acquired the knowledge of transfusions from Italy. As for their use, all we have is an entry in team doctor Bertus Fok's diary for 11 July 1988, at the end of the stage from Nancy to Strasbourg, showing that Steven Rooks, Gert-Jan Theunisse and Jörg Müller all received blood, on top of the other products Fok was administering (which included testosterone and cortisone). The Nancy-Strasbourg stage had been the 1988 Tour's first day in the hills, the peloton passing through the Vosges. That was followed by a sprinters' stage down to Besançon, with the race entering the Alps on 13 July and tackling Alpe d'Huez the next day. It was on the Alpe that the PDM riders shone, Rooks and Theunisse claiming a Dutch one-two, with their former teammate Pedro Delgado coming home third and claiming the maillot jaune. After that came the race's second individual time trial, where Delgado solidified his lead in the race. And tested positive for probenecid. It's also where Theunisse popped a positive for testosterone. The seventy-fifth Tour has gone down in cycling history not so much for the victory of Pedro Delgado as for the doping scandal that enveloped him in the last week of the race. Probenecid was banned by the IOC but wasn't due to be added to the UCI's banned list until a few weeks after the Tour ended. After first having denied taking any medicine, and after suggesting a spiked bottle must have been passed up to him on the road, Delgado did admit to having used probenecid, as prescribed by his doctor, François Bellocq: "Between Dr Bellocq and me," Delgado said at the time, "it's a question of trust. I have a problem with acid in my urine and we've been watching it for a long time." It was Bellocq who Delgado nominated to attend the testing of the B-sample on his behalf. But Bellocq, for some reason, sought to distance himself from Delgado, writing to l'Équipe that he hadn't treated the Spaniard. This was somewhat unusual. Bellocq was a doctor with a reputation and it's usually the dopers who try to publicly distance themselves from such doctors. This time, the doctor was distancing himself from the doper. And Bellocq wasn't the only one putting distance between himself and Delgado. Eufemiano Fuentes also denied having treated Delgado. Fuentes had started the cycling part of his career in 1985 with the Orbea squad, staying with them through to 1988, by which time they had become Caja Rural. One of Orbea's riders in 1985 was Pedro Delgado. In 1986 and 1987 Delgado rode for PDM, before returning to Reynolds in 1988, the team he had started his professional career with in 1982. Even though there was just that single season connecting them at Orbea, Fuentes was still linked by some in the Spanish media to Delgado. A link which Fuentes at the time denied. But which some claim Delgado confirmed, years later. Fuentes had, even then, already established a reputation for doping. He himself had been an athlete in the 1970s, a 400 metre hurdler, right at the time that blood transfusions were being talked about openly in track and field circles. Fuentes' involvement with the Spanish athletics squad at the Los Angeles Olympics is thought to have involved him doping his charges with steroids. Some say he was utilising transfusions by the time the Seoul Games came around, and most seem clear that blood doping was definitely part of his game plan in the Barcelona Games of 1992, but whether that was EPO or transfusions is unclear. The point about bringing Fuentes into the story here is not to suggest a link to blood transfusions in 1988, that Delgado's probenecid bust was an early echo positive – that would be too much dot joining – but rather to show how the backroom stars of Gen-EPO were already on the stage even before the drug arrived. Don't forget that, as well as Fuentes at Caja Rural, you also have to take into account the presence of Michele Ferrari at the Château d'Ax team that year. Fuentes is most famously linked to transfusions through Operación Puerto, with most of the evidence there coming from the early years of the new millennium, when transfusions are understood to have come back into fashion. But can we link Fuentes to blood transfusions before they are thought to have fallen out of favour? There is an infamous story concerning Fuentes and the 1991 Vuelta a España, which may or may not concern transfusions. Flying into Mallorca in the Canary Islands, scene of the race's stage eight individual time trial, Fuentes is said to have had a cooler bag (or box) on the seat beside him on the plane (or on his lap – the details vary from telling to telling). The cooler's contents, Fuentes told journalists, held the key to the Vuelta. A Vuelta which was won by the man who won that individual time trial Fuentes flew in for: Melchor Mauri from Manolo Sáiz's ONCE team. The team Fuentes had been working with since the previous season. What was in that cooler is not clear. We know that both EPO and blood bags would require the use of a cooler for transportation, and in 1991 either could have been in use. We know that EPO was coming into use at that stage, its influence spreading throughout the professional peloton. But we do not when different teams started using it. Even if EPO was in use at ONCE in 1991, why it would be necessary to fly it in during a race is not clear. The drug wasn't illegal in Spain and the UCI were only about to add it to the banned list. There is no reason why the team cars couldn't have been fully stocked at the start of the race. Flying in fresh blood bags, on the other hand, does make sense. But that doesn't mean it was blood in that cooler Fuentes was carrying. As well as blood and EPO, you might want to use a cooler to keep sandwiches fresh and that may have been all Fuentes was transporting. Maybe Mauri really did win that race on pan y agua. We do not know. Skip forward a decade. Gen-EPO has blossomed and bloomed but now a test for the drug is available and its use has been restricted, somewhat. Transfusions, which at this stage are supposed to have been a thing of the past, re-enter the picture. Pretty much from the moment the EPO tests arrived – at the Sydney Olympics in 2000 and ahead of the 2001 Classics season – transfusions were being whispered about. The first major evidence of their use came in 2004 when Jesus Manzano spilled the beans to AS about what had been going on at the Kelme team. Fuentes was suddenly the star of a new era of doping. But he is not the one who got the show on the road. From the recent USADA report we know that the USPS squad, with Michele Ferrari acting as their training consultant, had used transfusions during the 2000 Tour. From the Ferrara investigation into Francesco Conconi and his colleagues we know that, during searches, a bag of blood was recovered in 1999. From the Freiburg report, we know that as early as 1998 Telekom's doctor, Lothar Henrich, had begun experimenting with transfusions. In 1997 the haematocrit test was introduced. It is not inconceivable that, as soon as that arrived, some began turning to transfusions as a means of fighting the restrictions the H-test was imposing upon them and didn't need to wait for an actual EPO test to spur them on. The evidence from the USADA report, the Ferrara investigation, the Freiburg report, it requires just a minor adjustment to the received wisdom about the use of transfusions, it can be made to fit the accepted picture, the picture which shows that transfusions fell out of favour and only returned as EPO use was restricted. But how do we explain the use of transfusions as early as 1996? The evidence for this comes from Tyler Hamilton's "The Secret Race". In that it is claimed that Bjarne Riis admitted that blood transfusions had been part of his arsenal in the 1996 Tour. Here's what Hamilton had to say on that subject: "Bjarne told me how, in his 1996 Tour de France victory, he'd done three transfusions: one just before the Tour started, and one on each of the two rest days. He explained the reasons they worked so well; how, unlike the slow rise in haematocrit created by EPO, transfusions provided an instant boost of around three points, which correlated to a three percent increase in power. They were like a fountain of youth." While Riis was part of the Telekom team at this point and they had Jeff d'Hont as soigneur and Lothar Henrich as team doctor, the Dane seems to have managed his own preparation. Riis was using the services of Luigi Cecchini as his personal coach, the two having first met at Ariostea in 1992. Riis has always denied that Cecchini was hands-on with regard to the actual doping, so who assisted Riis's transfusions is not known. Both Riis and Cecchini have been linked to Fuentes but, in 1996, those links appear to have been in the future. Cecchini claims not to have met Fuentes before 2001. Riis, of course, denies any link to Fuentes. Where Fuentes was working in 1996 is not clear. After finishing with ONCE in 1991 he worked with Amaya, who folded in 1993. He's then not heard of in cycling until he joined Kelme, which is understood to have been 1998. The dots may all be there, but there is no reason to join them and link Fuentes to Riis's use of transfusions in 1996. You need to find another fall-guy for that. Conclusion: Pop-guns vs. howitzers So what have we got here? We have evidence pushing back the point from which transfusions were thought to have disappeared from cycling, going beyond 1984 and suggesting they were in use as late as 1988. We have evidence pulling forward the point at which transfusions reappeared in cycling, suggesting they were is use as early as 1996. What we don't have is any evidence from any riders that this new evidence can be believed. As has been acknowledged, no PDM rider has thought to mention the use of transfusions up to now, even though several have confessed to doping. Bjarne Riis didn't think to mention transfusions, either in his 2007 confession or in his autobiography, "Stages of Light and Dark". If cycling's history over the last four decades is blood steeped, so far it's been well hidden behind the curtain of silence. Why does the role played by transfusions in the years before Gen-EPO matter? Why does the role played by transfusions during Gen-EPO matter? It matters because it alters our perception of what happened in those years. Many cycling fans have a somewhat rose-tinted view of doping in the years before Gen-EPO, comparing the two eras to pop-guns versus howitzers. Doping is an arms race, and in an arms race you move from pop-guns to howitzers and on past intercontinental ballistic missiles. If blood transfusions were part of the armoury the pop-guns versus howitzers view needs to be reconsidered. You can compare EPO to howitzers if you want, but you cannot say that transfusions were just pop-guns. The path from transfusions to EPO is clear and unambiguous. In one you inject red blood cells into the body, in the other you inject a hormone that stimulates the production of red blood cells. For the men who worked with transfusions in the 1970s and 1980s, the progression to EPO was as natural as upgrading your smart phone. One might be more powerful than the other, or at least easier to use, but the two are, in essence, the same thing. But there is another link between EPO and the doping that was going on before Gen-EPO came along. Let's reintroduce François Bellocq into this story, the man who denied having been Pedro Delgado's doctor in 1988. Bellocq was an early champion of what is know as hormone rebalancing, topping up depleted cortisone and testosterone levels. In 1991 Bellocq published a book, "Sport et Dopage - Le Grande Hypocrisie", which explained his thinking: "I believe that the limits of sports medicine amount to stopping an athlete from digging into his body's resources, and replenishing a body from which professional sport demands so much." Replenishing, though, is where the problems arise. Over the course of a stage race, a rider's testosterone levels will naturally fall. As will their levels of other hormones, such as cortisone (EPO, it should be pointed out, is also a hormone, one which regulates the production of red blood cells, which like testosterone get depleted over the course of a stage race). Bellocq simply advocated rebalancing those levels. Whatever the body naturally used and couldn't replace quick enough, well it was permissible to top that up to its natural levels. The problems with the hormonal rebalancing argument begin when you start to question how you draw the line between topping up to a natural level and over-filling the tank. What, in other words, is the difference between hormone rebalancing and doping? Richard Moore, in his "In Search of Robert Millar", notes Bellocq's answer to that question, taken from "Sport et Dopage": the difference is the same as "the difference between the love of a good wine and alcoholism." Except that, stretching Bellocq's analogy, this was the age of Prohibition and the doctors were running speak-easies. Among the riders who beat a path to Bellocq's door – a long list of the great and the good of the sport – was Bernard Hinault. Philippe Brunel interviewed le blaireau for l'Équipe in 1999 and, after questioning Hinault on the topic of hormone rebalancing, moved on to blood doping. Here's what Hinault had to say to Brunel: "Moser made use of auto-transfusion. So he was playing with his own blood. He did no more no less that the Finnish athletes, Lasse Virén and the others. It suffices to take some of one's own blood during the Spring when it is rich, hyper-oxygenated, and to re-inject it when one is fatigued. Is that really doping? Maybe not, except if the blood is placed into a machine to re-oxygenate it to the maximum." Hormone rebalancing, blood transfusions, EPO, they really aren't all that different. The members of Gen-EPO, were they really all that different from the generations that went before them? Scapegoating them for doing the same as the generations that had preceded them had done, does that really make sense? But they're the ones who are going to be held accountable. They're the ones who we are clamouring for truth from. While we sit back and watch the generations who preceded ride off into the sunset in glorious silence, never to be held to account for the role they played in creating Gen-EPO. Because they were only playing with pop-guns.