Discussion

England scored the highest overall in terms of the criteria considered in this paper, but we are not arguing that England should be awarded the World Cup in 2018 or 2022 on the basis of these results. Rather, the analysis shows that it is possible to construct questions to meaningfully compare bidding countries based on physical activity and sports medicine criteria. It is well established that physical activity is a key risk factor for type 2 diabetes, cardiovascular disease and cancer, which, together with chronic respiratory disease, account for more than 60% of all deaths.16 21 Physical activity and public health measures were chosen on the basis that they are critically important areas, particularly given the current obesity epidemic. Sports medicine performance was included not only because of its direct contribution to world class sporting events through treating injuries, but also because of its substantial role in supporting relevant research into areas such as injury prevention, training and rehabilitation.22

We note that for some questions, none of the bidding countries scored the maximum available points. In our view, the highest score should represent the ‘gold standard’ that countries should be striving for. For example, in response to question 2, no country scored 10 points for the length of its sports medicine training programme (this required having a training programme of 5 years or longer). However, Finland, which is not a bidding country, does meet this criterion, as it has a 5-year sports medicine training programme.10 11 The length of the sports training programme is seen as a useful indicator of the importance placed on sports medicine in a country, and we chose this because of the recently published comparison between many countries, using this criterion. However, it is not the only measure that might be used for in this area, and it may be, for example, that it is more appropriate to look at the minimum time required from commencing work as a doctor to qualify as a sports medicine physician.

Similarly, no country scored 10 points in response to Question 4: government funding for treatment of sports injuries (this required the government to fully fund treatment of sports injuries with no significant waiting list). In contrast, New Zealand, meets this criterion through its Accident Compensation Corporation scheme.23 24

The literature search for question 3 focused on sports medicine articles, but it would be possible to include exercise-related articles from a broader, public health perspective, which may provide a better indicator of a country's overall approach to exercise, although at the expense of not focusing as much on sport.

We would have liked to include several other qualitative measures in the scorecard that are relevant to activity and health in the community, such as availability of public bicycle paths, quality of public transport and ease of access to community sporting facilities. Unfortunately, there was no readily available comparative information for the bidding countries to allow these measures to be included. It is also likely that the availability of infrastructure which promotes physical activity would be somewhat reflected in a country's physical activity prevalence rates, which we did take into account. It would also be possible to weight the included questions differently if it was considered that certain aspects were more important than others.

We consider that FIFA and other bodies overseeing international sporting events may wish to consider developing guidelines and/or requiring bidding countries to make submissions and be assessed on these sorts of criteria. We note that FIFA has recently announced its Football for Health programme25 and the football and malaria programme.26 These positive initiatives are certainly to be commended. Our proposal is slightly different in focus and timing, as it involves all bidding countries, and ideally encourages increased physical activity years before the actual sporting event. Our proposal is certainly not the only proposal that could work: a range of other options could also be suggested.

The fact that England scored highly on the questions that we posed may in part be explained by the fact that England's bid for the London Olympics seems to have been the first proposal of this type to aim to substantially use a successful bid to promote national physical activity.27 Although the English bid was only made in the last decade, some specific action was taken as part of the bidding process (eg, the development of a specialty training programme in sports medicine). National physical activity rates may take longer than this to change. However, if countries believed that their eligibility to host major sporting events would be handicapped if they did not devote significant resources to improving physical activity rates, then more comprehensive programmes may be instituted to try to increase physical activity. Many experts in the USA have claimed that it is ‘impossible’ for this country to provide universal healthcare to its citizens. The decision to put this reform in the ‘too hard basket’ may be reviewed by even the most strident opponents of universal healthcare if it was explicit that the absence of this reform could negatively affect the USA's chances of being chosen for major sporting events in the future.

We acknowledge that the scorecard proposed in this paper may to some extent discriminate against poorer countries. However, some measures, such as obesity and physical inactivity, are likely to be lower (and therefore score better in our model) for poorer countries. Further, poorer countries are likely to face similar disadvantages in meeting current criteria included by sporting events organisers, such as availability of stadiums, media facilities, hospitals, etc. We also note that our scorecard as shown in table 1 may discriminate against countries for which data were not readily, publicly available. That is, it may discriminate against non-English speaking and/or non-European countries. However, if these sorts of sports promotion and physical activity criteria were required by international sporting event organisers, we consider that individual countries would have ample time (and incentive) to discover/record relevant data. Therefore, it is unlikely that in practice such a system would discriminate against countries with less publicly available data. It would be possible to make some sort of adjustment based on a country's overall wealth. However, the comparison in this paper is designed to describe what a country has achieved, not primarily how well it has achieved in this area given the resources available, and most available measures of national wealth are very coarse indicators of these resources.

Major international sporting events have many potential benefits for the host nation. It is arguable whether increased sporting activity is, or is not, one of these benefits.3,–,6 However, if bidding criteria included aspects directly related to the physical activity of the population of the bidding countries, and the intellectual and physical infrastructure available to support such physical activity, it is very likely that there would be a long-lasting improvement in the physical activity and health of the bidding country's population. This would be a very positive and popular legacy to result from the hosting of, or indeed the bidding for, a major sporting event.

We are not suggesting that these measures be the sole criteria for awarding the 2018 World Cup. Rather, we recommend that bidding countries be required to make submissions on health criteria such as these, and suggest that FIFA and other sporting event organisers may wish to take these into account when determining the successful bidder. The London Olympic bid included reference to similar criteria,27 and we would encourage event organisers to consider including these types of questions. It also may be useful to include minimum criteria.