A LETTER FROM: Iten, Kenya
– Written by Stéphane Bermon, Monaco
I am a specialist in Sports Medicine and an Exercise Physiologist who have worked in these fields for more than 30 years. Having my clinical practice based in Monaco also helped me, long ago, to be acquainted with colleagues and staff from the International Association of Athletics Federations (now World Athletics). Twenty years ago, I was asked by one of them to become a member of the Medical and Antidoping Commission of this prestigious international federation. As an Athletics fan since my young age, witnessing live Said Aouita and Steve Cram running sub 3 min 30s in an epic 1500 m at Nikaïa, it did not take long to give a positive answer, which I never regretted. Twenty years, dozens of international championships, hundreds of meetings, conferences, and thousands of sports medicine consultations later, I was asked whether I would be interested in training two Kenyan healthcare professionals as a part of a pilot pedagogical program involving the Université Côte d’Azur and funded by the French Embassy in Nairobi.
For Athletics connoisseurs, Kenya is a major Athletics country feeding—for several decades—the elite field with the best middle- and long-distance runners alongside Ethiopians, and more recently Ugandans. Having been in Kenya many times before to supervise the medical care of international athletics events or running applied research projects with my Swedish colleagues, I was not naïve on the high injury rates, doping and the limited medical care provided to athletes. I felt that this proposal of training Kenyan colleagues would represent, for me, a unique opportunity to return to the basics and pause for a while my luxurious sports medicine practice as well as my high-level view from a sport governing body perspective. A kind of back to the basics indeed which, before I reach age sixty, could contrast very much with my comfortable positions of clinician in Monaco and Director of Health and Science at World Athletics respectively.
Having hosted two Kenyan colleagues from the Iten County hospital (Dr Castro Mugalla, a family doctor soon sports physician) and Mrs. Margaret Chirchir (head of physiotherapy) at the Monaco Institute of Sports Medicine for a month, as the first round of the collaborative project, it was now time for me to discover the Kenyan running ecosystem from the inside. The Iten County Hospital is very far away from the Western country standards in terms of medical diagnosis and care. However, running every morning a dedicated musculo-skeletal pathologies consultation with Castro and Margaret was a pleasure and an eye-opening experience that I recommend to any young healthcare professional involved in Athletics.
Iten, a city 2500 m above sea level, is no more and no less than an open experimental field for overuse injuries.
This statement might seem quite straightforward to some of you, but this is the reality of the situation. Indeed, it would likely take me a year of clinical practice in my Monaco office to diagnose the same amount of overuse injuries in runners I have seen in a week’s consultations in Iten. Diagnosing two stress fractures in the same runner (who is still training…) is possible over there! Beyond the sadness of each individual case, the various mechanisms supporting such astronomical injury rate are of particular interest, especially if one want to later tackle this public health issue.
For those of you who are not familiar with the East African running ecosystem, it is first important to know that all these Kenyan villages or small cities like Eldoret, Iten, Kapsabet, Kericho… are rural areas where the average socio-economical and education levels are low. In these high-altitude locations of the Rift Valley region, distance running is seen by tens of thousands of teenagers and young adults as the only way to escape poverty and make a living for them and their family. Following the example of some successful Kenyan runners, thousands of young (and less young) runners invade the roadside verges every sunrise. For those who will not be hit by a car or a motorbike, the twice daily training is most of the time long, hard, uncontrolled by lack of real coaching, non-individualised and not monitored. During the weekly 220 km run, everyone is trying to keep up with the best whatever the price they have to pay (for example, a twisted ankle, a RED-S and stress fracture for the several unlucky ones). During my regular stays in Iten, I also gave lectures to the local fraternity of coaches, among whom very few had received a decent and basic coach education. As a result, I had a kind of schizophrenic experience there, trying to treat--every morning—overuse injuries resulting from the poor level or absence of coaching witnessed every afternoon; in other words: squaring the circle.
Unfortunately, the sad picture does not end there. Many of these young athletes do not have the money to ensure a sufficient daily calorie intake, let alone the money to treat the well-known somatic and psychological consequences of this low energy availability. To crown it all, this trauma factory operates in a context not only of competition to attract the eye of a potential agent, but, sadly also in a context of social violence, of which women athletes pay the highest price. Agnes Tirop, murdered by her husband, was one of them. An angel flew away! The lack of results and therefore of prize money is often violently reprimanded. The systematic plundering of the prize money won by the most talented and fortunate of these runners is commonplace and happens even more easily because nobody teaches these apprentice champions how to deal with frequent defeats, let alone the rare victories. Social violence is rampant; a far cry from the fantasy of the highland runners often described in running magazines.
It is therefore easy to imagine that some of these runners would be tempted to spend US$40 (over the counter at the local pharmacy) to buy a “stairway to Heaven.” Where Led Zeppelin would have used LSD, those desperate youngsters prefer a testosterone shot which could increase their chance of winning a US$5,000 prize money race, meaning a piece of land, some cattle and security for the rest of their lives.
Athletics Kenya, the national federation cannot really control the situation as most of their graduated or certified coaches stay in Nairobi where indeed very few athletes train on a regular basis. Why would this federation reform or improve a system that provided medals and podium positions in all major international competitions for decades? Kenya’s strength is also its weakness: talented athletes are so numerous and so motivated that the “broken” ones are immediately replaced by ten others waiting. Runners are consumable in the Rift Valley.
I guess you could now see all pieces of the puzzle: fierce competition in a landscape of socio-economic poverty, thousands of incredibly talented athletes, very limited medical care, poor and limited coaching, no preventive medicine facilities, undernutrition, lack of control from the Kenyan Athletics Federation, social violence, and doping. All these are linked and intricated.
Writing these lines, I as a World Athletics staff member, also want to take my share of responsibility here. Should we have acted earlier? Have we focused too much on the doping scandal (the tip of the iceberg) ignoring the deeper causes of this public health disaster? Were we blinded by the glitter of all these gold medals and their associated outstanding performances? Likely, yes.
However, I am still convinced that the open field experiment on overuse injuries and social violence can be progressively closed. A few of us, like my dear friends Dr Victor Bargoria from Moi University in Kenya, Professor Toomas Timpka from Linkoping University in Sweden, Professor Jeanick Brisswalter, President of University Côte d’Azur, and others, strongly believe that the long-term solution relies mostly on the development of Sports Science and Sports Medicine academic courses in Kenya. This will require time, goodwill, and money. All of us are working to finalise a European Union-funded Erasmus+ grant application entitled “Running for your life”. Are we looking for some redemption here? Maybe. Whatever the result of the bid, one should not give up. The problem we want to tackle here reflects—in my humble opinion—the core and the essence of Sports Medicine.
Stephane Bermon M.D., Ph.D.
World Athletics
Health and Science Department
Monaco
Contact: celeste.geertsema@aspetar.com
Further Reading
- Bargoria V, Timpka T, Jacobsson J, Halje K, Andersson C, Andersson G, Bermon S. Running for your life: A qualitative study of champion long-distance runners' strategies to sustain excellence in performance and health. J Sci Med Sport. 2020 Aug;23(8):715-720. doi: 10.1016/j.jsams.2020.01.008. Epub 2020 Jan 30. PMID: 32061524.
- Timpka T, Fagher K, Bargoria V, Gauffin H, Andersson C, Jacobsson J, Nyce J, Bermon S. 'The Little Engine That Could': A Qualitative Study of Medical Service Access and Effectiveness among Adolescent Athletics Athletes Competing at the Highest International Level. Int J Environ Res Public Health. 2021 Jul 7;18(14):7278. doi: 10.3390/ijerph18147278. PMID: 34299729; PMCID: PMC8304016.
- Timpka T, Dahlström Ö, Fagher K, Adami PE, Andersson C, Jacobsson J, Svedin CG, Bermon S. Vulnerability and stressors on the pathway to depression in a global cohort of young athletics (track and field) athletes. Sci Rep. 2022 May 12;12(1):7901. doi: 10.1038/s41598-022-12145-0. PMID: 35552502; PMCID: PMC9098515.
- Timpka T, Fagher K, Bargoria V, Andersson C, Jacobsson J, Gauffin H, Hansson PO, Adami PE, Bermon S, Dahlström Ö. Injury acknowledgement by reduction of sports load in world-leading athletics (track and field) athletes varies with their musculoskeletal health literacy and the socioeconomic environment. Br J Sports Med. 2023 Jul;57(13):849-854. doi: 10.1136/bjsports-2022-106007. Epub 2023 Mar 31. PMID: 37001981; PMCID: PMC10359528.
- Mountjoy M, Ackerman KE, Bailey DM, Burke LM, Constantini N, Hackney AC, Heikura IA, Melin A, Pensgaard AM, Stellingwerff T, Sundgot-Borgen JK, Torstveit MK, Jacobsen AU, Verhagen E, Budgett R, Engebretsen L, Erdener U. 2023 International Olympic Committee's (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs). Br J Sports Med. 2023 Sep;57(17):1073-1097. doi: 10.1136/bjsports-2023-106994. PMID: 37752011.
- Stellingwerff T, Heikura IA, Meeusen R, Bermon S, Seiler S, Mountjoy ML, Burke LM. Overtraining Syndrome (OTS) and Relative Energy Deficiency in Sport (RED-S): Shared Pathways, Symptoms and Complexities. Sports Med. 2021 Nov;51(11):2251-2280. doi: 10.1007/s40279-021-01491-0. Epub 2021 Jun 28. PMID: 34181189.
- Bermon S, Adami PE, Dahlström Ö, Fagher K, Hautala J, Ek A, Anderson C, Jacobsson J, Svedin CG, Timpka T. Lifetime Prevalence of Verbal, Physical, and Sexual Abuses in Young Elite Athletics Athletes. Front Sports Act Living. 2021 May 31;3:657624. doi: 10.3389/fspor.2021.657624. PMID: 34136805; PMCID: PMC8200562.