‘Some athletes don’t listen to their bodies’: Dying to run the Comrades

Blanche Moila, 66, ran her first Comrades Marathon in 2000 and has completed the race every year since, apart from two when she was a race commentator. She is deeply saddened by the deaths of Phakamile Ntshiza, 47, and Mzameleni Mthembu, 43, during the race last Sunday.

“Sometimes athletes are on a high that keeps them going and then they collapse,” says the retired nursing sister, who finished strong last week. “Some athletes don’t listen to their bodies. When they are taking unusual strain, they should slow down or stop.”

Medical emergencies during the Comrades and other endurance events are relatively rare. Comrades chief medical officer, Dr Jeremy Boulter, says about 330 runners out of more than 13,000 entrants, ended up in the medical tent this year, mostly with fatigue and cramps.

“Some athletes are unaware of the risks when doing an endurance event while others know they are pushing the limits,” says sports medicine specialist Prof Jon Patricios from Wits Sports and Health (WiSH). “Some years ago a patient of mine had not done enough mileage in training for Comrades because of a knee injury. He went ahead against medical advice, and he died.”

A 58-year-old Cape Town doctor spent more than a week in ICU with kidney failure after a Comrades. An experienced ultra-marathon runner, she had not run in the six weeks since finishing the Two Oceans because of a hamstring injury, doing other training instead.

Doctors interviewed are unanimous that the benefits of physical activity far outweigh the risks. Says cardiologist and Comrades veteran, Dr Joe Tyrell: “The exercise paradox is this: it is better to exercise regularly than not, but while exercising there is a risk something bad could happen. It is a short-term risk versus a long-term gain.”

On race day a runner’s training, health, hydration, food, medicines, pacing and attitude are paramount to safety, but the lottery of genetics determines whether an individual has inherited conditions that could be life-threatening. 

This is why pre-race screening and medical check-ups are essential. For the first time this year, Comrades runners had to complete a health questionnaire before the race — a critical step for organisers to flag high-risk participants, plan medical support along the route and try to mitigate medical complications arising on the day. A similar compulsory questionnaire was introduced by the Two Oceans Marathon organisers five years ago. After receiving the completed questionnaires, Boulter’s team contacted runners identified as high risk to urge them to do a full medical check-up before the race. 

Comrades is the equivalent of “two standard marathons plus a Park Run” says race organiser Mqondisi Ngcobo, and urged runners to prepare safely and do the pre-race check-ups.

Cardiovascular risks increase with age — in Comrades the biggest group of participants is the 40 to 49 — age group — though they aren’t limited to older people. 

“If older people drop dead it is usually vascular disease. Heart attacks appear to come out of the blue but they need years of preparation,” says Tyrell. “With younger people there is usually some underlying form of heart disease that has not been detected.”

Dr Leigh Gordon from Cape Sports Medicine says all runners should do pre-race medical screening, not only ultra-marathoners. “In the Two Oceans medical tent we have proportionally more runners from the 10km and 21km races who are not as well conditioned. They have a higher rate of complications because they do not recognise the risks.”

An infection before the race or on the day can prove fatal and the sports doctors urge athletes to withdraw from events if they aren’t well. 

“Almost invariably our serious cases come from illness, usually a virus, in the previous three weeks,” says Boulter, who has been the Comrades Marathon Association doctor for 27 years.

“Another big problem is taking medication, like anti-inflammatories, on the route ... we tell the athletes not to take anything to numb the pain,” he says, but some still run with a pouch containing tablets.

Anti-pain medicines can cause kidney complications, affect the liver, heart and stomach, and be life-threatening, says Gordon. “People take the meds when they are feeling ill or have an injury, which can affect their kidneys and, if it is hot [on race day], they dehydrate more [quickly]. This is a perfect storm for things to go wrong.”

Cape Town anaesthetist Dr Pieter Roux was 45 when he suffered kidney failure after finishing the 200km Wines2Whales cycle race and taking ibuprofen for cramps during the event. “I was well hydrated and finished but I was not producing any urine and by the evening I felt terribly ill,” he says.

About 2,500 years ago a running-courier in the Greek-Persian war, 40-year-old Phidippides, collapsed and died after running 42km from a battlefield near Marathon, Greece, to Athens with news of a Greek victory.

That is the origin the modern marathon.

—  Fatal Origins

“I was admitted to hospital and it was the worst week of my life. I felt so bad I would rather die,” says Roux, who suffered more than when he had chemotherapy for early-stage testicular cancer (which may have damaged his kidneys).

“I have done long events at more relaxed pace after that but nowadays enjoy moderate exercise for the health benefits, camaraderie and coffee with my mates,” he says.

Genetics, as well as training and attitude, shaped the experiences of two mountain bikers participating in one of SA’s most gruelling endurance events, the 2,150km Freedom Challenge/RaSA (Race Across SA).

In 2019 Sandy Maytham-Bailey, then 56, was the only woman to finish the race which was held in fierce winds and sub-zero temperatures.

In the six weeks leading up to race day she didn’t do any cycling after developing “leaky gut” from overtraining. RaSA veterans advised training 140km a week but the distances hammered her body, forcing her to rest.

“I did exactly what I was told to do by a dietitian and poured my energy into mapwork (no GPS is allowed),” says Maytham-Bailey. “I finished RaSA better off than most of the guys.

“Every day I rode 10 to 16 hours and I finished in 21 days. The cut off was 26 days,” she says. “It is important for athletes to get their information from the right sources which is right for their bodies.”

Another RaSA enthusiast is Mike Roy, who narrowly escaped death after doing the extreme ride twice. In 2009 he rode but missed the cut-off, and nine months later he suffered a heart attack. 

Undeterred, the mentally tough rider returned in 2015 after an ECG and clearance from a cardiologist, though he was carrying some extra weight. He completed the ride one day after the cut-off despite going through hell with two undetected blocked arteries.

Five day later he had a heart attack which has left him with severe arrhythmias (atrial fibrillation). Nevertheless Roy says: “I may well have had a heart attack anyway, and the fact that my heart was strong from years of endurance sport may have saved me.”

“I continue to ride ... just in a more controlled way. No more Freedom Challenges, hence I have switching to the volunteering.” For a few years he has been helping riders stay safe along the route.

“Most of us are not in the first flush of youth and we overestimate our ability,” says Roy. “We think we are super athletes and that we are bulletproof.”

Patricios says: “The first risk to athletes is genetics, and the second is people’s own current health status, both chronic conditions and acute infections.”

While older athletes cope with chronic conditions such as structural changes in the heart and blood vessels, some young athletes across a range of sports die of sudden cardiac arrest because of inherited conditions.

• 400,000-plus have finished the race since the first in 1921

—  Comrades in Numbers

Roughly half of the young athletes have no symptoms, but a thorough family history can raise red flags. 

“Some highly conditioned, elite athletes can die without warning,” says Patricios, which is why medical support at events is critical. “The sooner athletes with cardiac arrest get help the better their chances of survival. This is more difficult to control over 90km of road versus inside a stadium.”

For event organisers another concern is the health of “weekend warriors” who do not have the experience and fitness of elite athletes when competing.

Dr Darren Green, event medicine specialist for Mediclinic — which supports the Cape Town Marathon, rugby tours and the Wine to Whales — reiterates that pre-race screening is vital.

“Advance screening can curb unwarranted, unnecessary deaths and we are working hard to introduce this across the globe,” he says.

“When we have athletes’ medical history (linked to a race number), for example, allergies, we know how to treat them on race day,” he says. This is crucial when planning medical support, refreshment stations and water stops. On event day they also measure conditions, including humidity and wind, and adapt to them.

The accessibility of events such as marathons to everyone has pushed up the risk, says SPN Africa running writer Stephen Granger.

“In the early days of road running, the only people who ran were serious athletes and no-one died,” he says. “When I did my first Two Oceans there were 160 runners.

“That was before marathons all around the world became more accessible and like ‘fun runs’,” he says, “and the Comrades is seen in the same light.”

• Eight runners have died on the route

—  Comrades in Numbers

Runners underestimate the jump from a marathon to an ultra, says Patricios. Six months is not enough time for a novice to train for the Comrades. 

Novices inevitably make mistakes, says Boulter, who gives talks to running clubs and offers advice to them ahead of the iconic ultra. “On the day novices may not know how to pace themselves, what to eat and drink, or may not have the miles they need in their legs.”

Yet often the minds of the A-type personalities and high achievers who compete in ultra-races are steely enough to override their safety signals.

This decision to “toughen up and go on” can be dangerous, says Roux, who wants to prevent people from experiencing post-race hospitalisation. “If you feel ill, you should stop. Things can go wrong. I learnt I was not indestructible.

“The risk lies in doing extreme endurance exercise on a regular basis and not listening to your body during events. Who has the wisdom and common sense to stop at 50km of a 90km event when swept up in the camaraderie and hype?”

Roux questions whether the modern obsession with extreme exercise is healthy, referring to publications by Canadian cardiologist Dr James O’Keefe about the benefits of moderate exercise.

“Even though chronic extreme exercise may not kill you, it may erase many of the health advantages of regular moderate exercise,” writes O’Keefe in an BMJ Heart editorial titled “Run for your life ... at a comfortable speed and not too far”.

Regular extreme exercise “appears to cause excessive ‘wear-and-tear’ on the heart”, which offsets some of the cardiovascular and longevity benefits gained from moderate physical activity, O’Keefe says. 

On that point, Patricios adds: “Running is an outstanding activity and very accessible. The question is whether there is more benefit to running 90km than regularly running 10km?”