2019 Marathon des Sables, a six-day ultramarathon through the Sahara Desert. Credit: Ryan Christopher Jones for The New York Times
What is an Ultramarathon?
Any footrace longer than a marathon (26.2 miles or 42.195km).
Who Runs Ultramarathons?
Anybody. Thanks to social media, websites like ultrasignup.com, and increasing interest in extreme sporting events, more people than ever are participating in ultramarathons. Participants range from experienced runners and sponsored athletes to individuals with little to no running experience seeking a new challenge. In 2018, over 600,000 people ran an ultramarathon, representing a 1,676% increase in participation since the late 1990s. This number has only continued to grow.
What Happens When Ultramarathons Go Wrong?
In May 2021, the Gansu Ultramarathon disaster in Gansu, China, resulted in the deaths of 21 runners (12% of the total field) from hypothermia, with another eight hospitalized during the 62-mile (100 km) race in a remote mountain region.
The cause of the deaths is debated, but most attribute it to a combination of poor planning by local organizers, atypical weather for the season, too few aid stations and monitors, underprepared runners, and slow medical response time due to the race’s remoteness.
While the Gansu Ultramarathon was unique in its scale of tragedy, it is not the only deadly ultramarathon. In June 2024, during the Ultra Trail of Haut-Giffre (UTHG) race in France, one participant lost their life and at least two others were severely injured and hospitalized after being caught in a storm in the French Alps.
Deaths have increased during ultras due to the growing number of participants and the inclusion of less experienced athletes, with sudden cardiac arrest being the most predominant cause of death.
Are There Any International Regulations Governing Ultramarathons?
No. Unlike other organized marathons or Olympic running, there is no centralized set of rules or governing body overseeing all ultramarathons. One emerging organization is the International Association of Ultrarunners (IAU) which operates under World Athletics (formerly known as the IAAF) and set the rules and regulations for various types of ultramarathon events. However, many races still operate with their own set of rules and regulations.
This lack of standard regulations can lead to events that seem to place safety as an afterthought, purposely pushing human physiology to its limits. For instance, the Badwater Ultramarathon, a 135-mile (217 km) race, takes place in mid-July in Death Valley, one of the hottest places on earth, and has had temperatures hit as high as 127°F (53°C) during races.
Are There Any Accepted Universal Medical Guidelines for Ultramarathons?
There are no specific or universal standards of medical care for ultra-endurance foot races. Dr. Martin Hoffman and his team addressed coverage of these events in their paper, “Medical Services at Ultra-Endurance Foot Races in Remote Environments: Medical Issues and Consensus Guidelines.” They discuss common ailments that can occur during an ultramarathon, such as hyponatremia, heat stroke, and acute kidney injury (AKI), and provide guidance on recognizing and treating these conditions for those interested in further reading.
Ethically, Should Physicians Be Volunteering or Working at Ultramarathons?
Ultramarathons are inherently dangerous, even under perfect weather conditions and with proper training, due to the extreme stress they place on the human body and the remote environments they can take place in. Given the nature of these races and the fact that we have all taken the Hippocratic or Osteopathic Oath, pledging to do no harm and to preserve the health of our patients, ethical questions arise regarding the participation of medical professionals.
Do runners expect medical professionals to be present during races?
A 2019 study explored ultramarathon participants' opinions and expectations regarding medical services at races. Over 1,100 athletes who had completed at least one 50K or longer race responded. Of those, 83.2% agreed that ultramarathons should provide a minimum level of medical support, with basic first aid and emergency transport services rated as the most essential. While participant safety was viewed as a shared responsibility between each runner and the race or medical director, 91.5% of respondents felt that races should disclose the availability of medical services.
Should medical or race directors cancel or stop an ultramarathon if environmental conditions pose a significant risk to participants?
In response, 78.2% of surveyed participants agreed that altering or canceling a race would be appropriate under extreme environmental conditions, such as a nearby wildfire. This strong support can give medical directors confidence in making decisions to cancel a race when necessary, knowing that the majority of participants trust their judgment.
Does the presence of medical personnel encourage participation in extreme sports events that might otherwise be avoided?
Possibly. While no specific peer-reviewed studies I could find directly address this question, it’s plausible that medical personnel on-site could enhance participants' perception of safety, encouraging those who might otherwise hesitate. The previously mentioned study indicated that a majority of participants believe medical personnel should be available, suggesting that some runners might avoid events lacking medical support.
Would runners participate in ultramarathons without medical personnel present?
Yes, as many people engage in extreme sports without on-site medical providers. In the survey, 16.8% of respondents felt that ultramarathons don’t need to offer even minimal support, while others may prefer medical personnel but would still participate regardless.
Does having medical providers at extreme sporting events save lives?
Yes. Rapid medical intervention at sporting events can be lifesaving. Early detection, diagnosis, and rapid on-site cooling for exertional heat stroke have been shown to be highly effective in saving lives. When cold water immersion is applied within the first 30 minutes of collapse, survival rates can reach 100%, with around 93% of patients discharged the same day. In contrast, fatalities have occurred when slower or less effective cooling methods are used, or when cooling is delayed by transporting the patient before achieving a sufficient drop in core body temperature.
Do medical professionals overall cause more good than harm by being at an ultramarathon?
I've spoken with sports medicine physicians who believe that attending certain sports events, such as non-sanctioned mixed martial arts fights, is unethical or falls into a gray zone because their presence might validate and encourage participation in these dangerous activities. Could the same reasoning apply to ultramarathon races like the Badwater 135, which takes place in Death Valley in the summer, or the Habanero Hundred, which purposely occurs at high noon in August in Texas? One could argue yes. However, the potential encouragement is outweighed by the crucial help medical providers offer.
What steps can be taken to make ultramarathons safer?
One challenge in providing medical coverage during long-distance races is managing athletes who are spread out across vast, often remote areas with few checkpoints or spectators. This remoteness was a key factor in the Gansu marathon tragedy, where racers were scattered across miles of mountainous terrain, leading to delays in locating and treating those in need. To address this, technology can play a pivotal role in enhancing race safety.
In 2022, at the Montreal Marathon, a team of emergency physicians, race organizers, and drone pilots used drones to monitor participants. Their pilot study quickly turned into a real-world intervention when a drone spotted a runner in distress, allowing emergency responders to be directed to the runner’s exact location. As drones become more affordable and accessible, they could be valuable tools for race organizers, not only for monitoring but also potentially for delivering supplies—such as water, food, medication, or warm clothing—to distressed runners awaiting rescue.
GPS tracking and personal locator beacons (PLB) are another promising satellite-enhanced technology is racing safety. During a 332-km ultramarathon in Washington’s Cascade Mountains in 2017, a disoriented runner used his GPS device to alert his wife at the finish line. This signal allowed race officials to track his last known location and recognize he was off course, enabling a quicker and more accurate response that might otherwise have required extensive search resources.
Although it seems logical for all runners to carry a PLB during remote or multi-day races, opinions are mixed. In the previously mentioned survey, when asked if GPS devices should be mandated for such races, responses were split: 49.6% said "yes," 25.1% "no," and 25.3% were "unsure."
Additional steps include enhanced pre-race medical screenings and participant education. A study of the 56-km Two Oceans Marathon (2008–2011) showed that implementing these measures led to a 39% decrease in medical complications, including a 64% reduction in serious, life-threatening incidents. In the same survey, 65.8% of runners expressed interest in more pre-race medical and science presentations, underscoring both a desire for education and the demonstrated effectiveness of pre-screening and education in reducing medical events.
With the growing popularity of ultramarathons, the number of participants and races will likely continue to rise, often in increasingly remote and challenging locations. Consequently, the risk of accidents may grow as well. However, by adopting measures such as enhanced pre-screening, improved racer education, and advanced tracking technologies, we can support runners in pushing their limits and enjoying the outdoors more safely—and do so in an ethical manner.