No matter what the intricacies of the tennis star’s case are, the number of failed tests since the drug was banned demonstrates widespread misuse

Maria Sharapova is not the first athlete to fail a test for meldonium this year – distance runners dominated the previous week’s doping news for it. Nor will Sharapova be the last – Olympic and world champion speed and figure skaters followed her in short order, and new cases seem to be happening daily. She is, however, the most prominent symbol for now of the drug du jour, a relatively unknown Latvian medicine created to treat heart conditions but which is now gaining such exposure that it reportedly sold out of online stores in the aftermath of Sharapova’s confession.

Sharapova’s vague explanations and justifications for her own meldonium use did little to dissuade the view that she was taking it for performance-enhancement reasons. There was nothing wrong with doing so until 1 January this year, either. Given the enticement of the performance benefits, lack of side-effects and legality of meldonium, perhaps the only surprise is that only 2.2% of a sample of 8,320 athletes were using it (its use predominantly seems to be in eastern European nations because it is not Food and Drug Administration-approved in the US and unavailable in much of the world).

That use provoked the World Anti‑Doping Agency to put meldonium on its watch-list, monitoring and researching its use and effects, and then on the banned list this year. Wada would have made that decision for two reasons. First, meldonium was clearly being used widely enough by a population of elite athletes that really should have no business needing a drug for heart disease. Second, there are enough theoretical reasons to believe it does enhance performance.

Interestingly, the founder of meldonium came out to defend the drug (and Sharapova), suggesting it did not enhance performance but rather returned the athlete to a normal condition. He equated it to eating meat to help with recovery. That is disingenuous, because testosterone and growth hormone, both obvious doping products, do the same thing – any intervention that aids recovery means better training, and that means better performance.

More interestingly, the very same founder had previously authored an abstract to a sports science conference in which many benefits of meldonium were promised, including enhanced aerobic capabilities, endurance performance, and recovery. Wada would have noted this and developed the relevant tests – 2016’s spate of meldonium positives are the result.

With respect to Wada’s banned substance list, it is important to realise it is not carved in stone. Rather it is a fluid, changing document, and all athletes and medical personnel know this. There can be no expectation that things remain constant from year to year, and so medical staff and athletes have a known obligation to stay up to date, particularly when concerning scheduled medicines for serious conditions.

You could forgive an athlete for tripping up over herbal ingredients finding their way into supplements, as has happened in the past. But meldonium is no herbal supplement. Nor is it caffeine, or a multivitamin. It is an ischemic heart drug, created for people who are very sick – studies on patients with angina, a symptom of heart conditions, shows how severely exercise-intolerant they tend to be.

That this drug is being used by even one in 50 athletes (and one in six in Russia, where it is more readily available by virtue of its Latvian “birth”) should highlight the absurdity of it all – a regulated drug, prescription only, being more prevalent in elite athletes than in many elderly, ill populations is an untenable situation. Even the possibility of risk is grounds to ban it.

Since Sharapova’s announcement, many have argued that meldonium should not even be on the list given the relatively weak evidence for benefits, but this is just more obfuscation. The reality is that it is on the banned list, that this was communicated to athletes with plenty of warning, and that its presence on the list is entirely justified since it is a regulated medicine being used without any medical necessity.

The best case you can make for Sharapova is that she was grossly negligent. That she, along with her many advisers, failed to take heed of not one, but multiple alerts that meldonium was to be added to the banned list in 2016. That negligence need not be innocent, either. Ignoring the alerts may be entirely accidental, or it may be born of a disregard for anti-doping authorities. Perhaps in Maria Sharapova’s world, an email alert from Wada or the ITF concerning doping is the equivalent of the spam we receive from Nigerian banks?

A final option – the worst case – is deliberate use, and not much needs to be added to that. It would be conscious cheating, and worthy of every day of a four-year ban.

Time will tell which way the dice fall for Sharapova, and by extension, the mounting number of meldonium compatriots.

Professor Ross Tucker is an exercise physiologist and high performance sports science consultant