NBA faces major health, safety obstacles in return


If you don’t want to ruin a public health official’s day, steer clear of NASCAR’s return-to-play plans.

The sports world has been shut down across America since early March over concerns about the spread of the novel coronavirus, which has claimed the lives of over 100,000 Americans and infected over 2 million. 

But on Sunday, NASCAR is planning to open up Homestead-Miami Speedway to 1,000 South Florida service members and honorary guests, making NASCAR the first major sport to allow fans back into the stands. On the following Sunday, on June 21, NASCAR is planning to have 5,000 fans at Talladega Superspeedway in Alabama. 

NASCAR says it will practice social distancing and require all fans to wear masks, but there are still questions about how seriously they’ll be able to enforce those precautions with thousands of fans, especially if alcohol is involved.

“You look at that, as a public health professional, and you just want to cry. You really do,” said Dr. Zachary Binney, adjunct instructor in Epidemiology at Emory University Rollins School of Public Health and sports injury epidemiology consultant. 

Binney, on the other hand, feels much better about the NBA’s plan, which won’t involve fans in attendance at any time and plans to administer daily coronavirus tests to its players and staff. The league plans to return on July 30 with 22 teams living and playing at Walt Disney World Resort in Orlando. Unlike NASCAR, which takes place outdoors, basketball is played indoors where the virus can be transmitted more easily. 

“No plan is perfect,” Binney says. “The NBA is taking a lot of good steps here.”

The NBA hasn’t sent official health protocols to its teams yet, but there are some large strokes that have surfaced. In order to reduce possible transmission, the NBA has told the National Basketball Players Association that players are not allowed to have guests, including family members, until after the first round, likely to be at the end of August, according to multiple reports.

Will that be enough? The devil is in the details as they say. 

Regarding the NBA’s plan to combat the coronavirus, I spoke with two epidemiologists at Emory University Rollins School of Public Health, Binney and Dr. Neel Gandhi, an infectious disease expert and associate professor at the school, to address the trickier coronavirus questions.

Let’s break this down topic by topic.

NBA players may be quarantined, but what about the Disney staffers?

In some corners of the NBA, this is the most contentious point. When whispers about a possible NBA “bubble” began to circulate months ago, epidemiologists were concerned not just about protecting the NBA players and the league’s staff, but also about the hundreds of non-NBA staffers needed to clean, feed and maintain the massive operation.

Now that the NBA has planned to resume at Disney, there are now more specific questions about fully sequestering the location. Will the food servers be tested every day? The housekeepers? The custodians? More broadly: What’s the point of quarantining for several weeks and doing daily tests for 22 NBA teams if Disney staff won’t be doing the same? 

“This isn’t a bubble. This is a mesh hat,” says one high-level NBA executive who has been briefed on the NBA’s plans but isn’t authorized to speak publicly.

Disney workers have not been told to quarantine on campus, according to Eric Clinton, president of Disney’s labor union, United Here Local 362, which represents custodians and ride operators. Clinton told NBC Sports that it was “unlikely” that staffers would be subject to daily testing and quarantine measures like NBA players and team staffers.

There will be protocols in place, however. At this point, Disney staffers will be required to wear a mask at all times. Beginning June 14, per the latest labor agreement between Disney and the 38,000 members of Service Trades Council Union, Disney employees will be required to do a temperature check at a designated central location before proceeding to work. If the employee’s temperature is below 100.4, they will remain at work. If the employee’s temperature is at or above 100.4, the employee will be given “a cool-down period” and then undergo a recheck. If it remains at or above 100.4, the employee will be sent home.

Some executives and players have expressed concern about the double-standard of being held to such strict standards while Disney staffers are free to go home to their families and live at their residences. Some team officials have even suggested allowing teams to fly in and out on charter. If Disney staffers are free to come and go as they please, why can’t NBA players?

Gandhi, however, doesn’t see it that way. 

“I agree that that’s not ideal,” Gandhi says. “But I’m a little reluctant to say alright, let’s take a step even further back and allow even more people in and out. I would try to push to have the auxiliary staff in the bubble and increase the level of security.”

The NBA can limit face-to-face interactions. With some basic planning, it’s possible that housekeepers and NBA players may never meet. Payments at cashiers could be contactless. 

“The NBA players and staff will likely be in contact with each other a lot more than the Disney staff will be,” Binney says. “I think symptom checks would probably do enough to reduce it down to an acceptable risk level. This is not something I would have said two months ago, but we’re learning that the risk of person-to-object-to-person transmission is not a very common group. Person-to-person is a much bigger deal.”

What about Orange County infection rates?

The numbers coming out of central Florida are not trending in the right direction. According to the state health department, there are 2,678 total confirmed cases in Orange County, where Disney World is located, and the numbers are climbing fast. On Wednesday, the state reported 128 new cases in the county, by far the highest in at least 14 days. 

But Gandhi and Binney agree that raw totals can be misleading because a higher number of cases may be a result of simply more tests being administered. A more accurate measure of coronavirus spread may be a ratio of tests coming back positive. 

Orange County’s percent positive rate reached 6.2 percent on Wednesday, the highest in nine days. Last month, the World Health Organization recommended to governments that before reopening, rates of positivity in testing should remain at five percent or lower for at least 14 days. Wednesday marked the second time that the county trespassed that threshold.

“The more disease that’s on the ground in Orange County, the higher risk everybody is at,” Binney says.

With Disney staffers going back into their Orange County homes and re-entering the NBA’s bubble on a daily basis, the rising infections are a red flag for Gandhi and Binney and worth monitoring closely, though it isn’t high enough to pull the plug on the whole endeavor. 

At what level would the Orange County infections become too overwhelming? Gandhi and Binney both believe that hospitalization rates would be the top indicator on that front, but Florida is one of seven states that do not publish that data. The lack of hospitalization rates makes Binney and Gandhi uneasy about the NBA’s choice of Orlando, but they recognize that there’s no perfect solution here.

Said Binney: “There are two dueling forces: Who’s going to let you play and who’s going to likely not have an explosive outbreak? You have to find a balance because those two can sometimes be at odds. The places with the loosest regulations are less likely to shut it down.”

Gandhi also notes that the state of Florida faced allegations of manipulating the data in its coronavirus reports in its effort to reopen the economy and potentially attract large businesses (like, ahem, the NBA). It’s worth noting that NASCAR’s first race with fans will be held in South Florida and according to reports, the Republican National Convention is likely to be moved from Charlotte, NC., to Jacksonville, Fla.

The available metrics in Florida are not inspiring. Positive cases are up 93 percent over the last seven days compared to the previous seven days while testing over that same time period has gone up 27 percent.

“What you’d like to see is a locale to be stable or dropping. You don’t want to be on that upswing of the curve,” Gandhi says.

There’s still time for infection rates to thaw. The NBA is planning to have teams fly into Orlando in less than four weeks, but it’s safe to say that Orange County data is something the NBA and its players and staff will be keeping an eye on as the season approaches.

Who is most at risk?

There has been much debate about whether older coaches like Gregg Popovich (71 years old), Mike D’Antoni (69) and Alvin Gentry (65) should be treated differently than the rest of the NBA’s Orlando contingent. The CDC states that individuals 65 years or older are considered a high risk for severe illness from COVID-19. 

Should they wear a mask? Should they be allowed on the bench? Should they be allowed at all?

Last week, commissioner Adam Silver stated on TNT’s Inside the NBA that “certain coaches” may not be able to be on the bench when play resumes “in order to protect them.”

It’s not just those head coaches that fall in that age range. New Orleans assistant coach Jeff Bzdelik (67), Lakers assistant coach Lionel Hollins (66) and Houston assistant coach John Lucas (66) will be facing those CDC-issued concerns along with referees Ken Mauer (65) and Michael Smith (65). A source close to the situation told NBC Sports that older NBA referees have not yet been given word about whether they will be going to Orlando.

The expectation here is NBA head coaches will go to the bubble and perform their duties as leaders of the team, even if it means bypassing certain recommendations. According to ESPN, NBA team personnel are expected to volunteer medical records to a panel of physicians to assess their level of serious illness due to coronavirus. To Gandhi and Binney, it’s an important, if controversial, step toward treating each person as their own case, rather than grouping them in larger pools of people. 

“One of the things that distinguishes epidemiology from medicine is thinking about populations versus thinking about individuals,” Gandhi says. “What we’re talking about is probabilities. Among all 25-year olds, the likelihood that somebody would have a bad outcome is less than among all 71-year olds. But if you put one 71-year old versus one 25-year old, it’s true we can’t say the same.”

This echoes the point that Dallas Mavericks coach Rick Carlisle, the 60-year-old president of the National Basketball Coaches Association, made to ESPN’s Adrian Wojnarowski last week, saying Silver “admitted that he jumped the gun” in saying there might be special protocols in place for older coaches.

Gandhi says that the current scientific literature shows that age is a significant factor, even after controlling for other comorbidity factors. But it’s not enough to prohibit those 65 years old and up from going to Orlando. Binney agrees with that sentiment.

“I’d be really hard-pressed to say, ‘Hey Pop, don’t come to Orlando,’” Binney says. “I don’t know that there’s much that I would advise them to do that I wouldn’t advise everyone to do. Everybody wear a mask at all times when you’re not playing ball or in your room alone. I can’t speak to it from a legal perspective but you do want to recognize the risk and build a system that is safe for Pop. Don’t build a system that is safe for a 25-year-old but isn’t for Pop. Build one that is safe for Pop and by extension that is safe for other players.”

Putting aside the age dynamic, there is a racial component to the coronavirus that Gandhi and Binney wanted to address given that Black people are dying at a rate nearly two times higher than their population share, according to COVIDTracking. On the surface, that’s a staggering statistic, especially for a league whose player population is 75 percent Black. Does that mean that LeBron James, Giannis Antetokounmpo and Russell Westbrook are inherently more at risk than, say, Luka Doncic? Hardly. In reality, according to Binney and Gandhi, it points to why many players like James, Antetokounmpo and Westbrook are protesting around America.

“Black people are not dying more because they're Black,” Binney says. “They’re dying (more) because of systemic racism. They’re dying because of underlying social, political and economic systems that are leading them to having higher comorbidities, higher rates of being uninsured, worse treatment by our healthcare system. That’s more likely what we’re seeing. I don’t look at someone and say, because you’re Black, you’re higher risk. It’s because how Black people, on average, are treated in the system versus whites.”

To Gandhi, the “why” is more important than the “who,” especially when it comes to socioeconomic factors that come into play.

“Most people who have more money have larger houses and have greater ability to separate,” Gandhi says. “When we take the construct of African-Americans seem to be dying at higher rates than other races, and try to apply it to the NBA, it doesn’t really fit. LeBron James may be African-American but his socioeconomic status and his ability to access healthcare is dramatically different than the average person. I think we need more nuance (in the conversation).”

Gandhi goes on to say that studies show that risk of becoming infected once you’re exposed is not likely to be affected by race. It’s not fair to say that Black NBA athletes are more susceptible to getting coronavirus than their white peers. But age does appear to be a significant variable in how people respond to infection, which is something that older individuals like Popovich and Mauer will have to weigh.

“The folks who are older,” Gandhi says, “are more likely to have a severe illness, more likely to be hospitalized and more likely to die.”

What about leaving the bubble?

When it comes to best practices for managing coronavirus risk, Gandhi points to the HIV epidemic as a lesson. Guidelines that insisted on total sexual abstinence did not work, at least not for long. The more effective model is to recognize human nature’s limitations and offer guidance on how to manage risky behavior -- or what epidemiologists call harm-reduction strategies.

Likewise, it’s hard for Binney and Gandhi to recommend a strict quarantine for six weeks in the NBA bubble as it’s currently constructed. Instead, Binney suggests teams outline a clear set of rules about acceptable reasons to leave the bubble and the possible sanctions or protocols that would follow. That way, players can determine the risks and benefits for themselves.

One compromise, Binney suggests, might be to have a selective program in which players can still do daily testing even when outside the bubble. In that case, if one player gets to leave, it’d be hard to imagine other players not trying to follow suit.

The NBA is planning to mandate a 10-day quarantine for any player that leaves the bubble, according to multiple reports. Gandhi believes the 10-day quarantine would not only protect players from potentially spreading the disease but that rule could also serve as a deterrent.

“I’d imagine that’s also a disincentive,” Gandhi says. “It’s one thing, ‘I’m going to miss three days to go home, but I’m going to miss all of the games in the next 10 days after I get back?’ 

Hopefully that creates a disincentive. I’d imagine there will be considerable peer pressure to say, ‘Hey, we need you, we can’t lose you for the next 10 days’.”

Like the HIV epidemic, you want to make sure players feel a sense of autonomy and control rather than feeling held hostage by the virus, which might hurt a player’s morale and overall adherence to the rules.

“Instead, you want to teach people how to reduce risk and reduce the harm from that risk, but not necessarily abstain,” Gandhi says. “We’re all in this area right now. We all are willing to take some risks, but we just have to be calculated on which risks to take.”

Leaving the bubble to tend to your family? Understandable. Leaving the bubble to go to a nightclub? Not so much. There’s a middle ground, which teams should strongly consider. 

Binney points out that he and his friends are planning to go to bar trivia on Monday night for the first time since the pandemic shut down. (Yes, epidemiologists have social lives.) But Binney says he spoke with the owner and it will be outside at spread-out tables. Masks are required and answers will be texted to the host, not delivered by hand like normal. Binney is making sure they won’t be sharing drinks or engaging in close contact with other people.

This is a harm-reduction strategy. It’s something for the NBA to keep in mind, especially if they allow players to break the bubble.

“If we’re going to restart the NBA, and you’re going to be able to be paid, then I’m sorry, you don’t get to go to nightclubs and try to meet people,” Binney said. “You just shouldn’t do that. You want to go and sit outside on the patio and dine or have a beer, or having a couple people over for barbecue outside ... keep it relatively small. I think those are some small things that we can start doing.”

Likewise, Gandhi has allowed his kids to return to youth sports, but with exceptions. Last week, his son stayed home rather than playing in a tournament that brought teams in from around the state of Georgia. That seemed prime for a super-spreader event. Meanwhile, his daughter goes to soccer practice, but only plays in games that are within their small town.

“Sporting events which bring together large numbers of people, they have a very high risk of a superspreading event,” Gandhi says. “Trivia at the bar on the outdoor patio with tables spread apart is a much lower likelihood.”

What’s worse: one infection on multiple teams or multiple infections on a single team?

The NBA has said that one positive test will not be enough to shut down the entire system, but little is known about the contingency plans around multiple positive tests.

“What I fear is the wildfire scenario,” Gandhi says. “Once something is introduced, how quickly is it going to spread? The multiple cases within a team is approximating that even more.”

Both scenarios are bad, but Gandhi believes multiple infections on the same team would be worse. This isn’t to downplay the seriousness of multiple teams having a single infection. That would suggest something different, that the league would have to tighten the bubble. Contact tracing would have to be initiated to find commonalities in those infections. Maybe a restaurant server or contact with golf course employees was the culprit.

“How is this virus getting in? You’d see if you could plug that,” Binney says.

But if the coronavirus spreads quickly within the team, it might cause a breakdown in the whole system. 

“If you see a cluster within a team, you would have to shut that team down for a couple weeks,” Binney says. “And how do you do that in the middle of the playoffs? That seems disastrous (competition-wise). If you saw multiple teams, each with clusters, that’s when you’d think things are getting out of control and you may need to bring the hammer down on everything. That would be the real nightmare scenario for me.”

Are there long-term concerns?

Playing in the NBA bubble shouldn’t be just a decision about the 2019-20 season. This should be a career decision.

“What we’re learning is that even if you don’t become so sick that you end up in ICU, there can be some very serious long-term symptoms associated,” says Gandhi. “For an athlete, that can be more devastating than for the average person.”

While the conversation of high risk is associated with older age, getting sick may have longer lasting effects. Imagine if a free-agent-to-be gets sick and misses the postseason. Uncertainty about the long-term impact may depress his earning potential on the market.

“We want to design a system that is keeping our older coaches and referees safe,” Gandhi says, “but we want to keep our younger individuals safe too, because if they were to lose a year of not being able to put up the stats they want, not being able to play the minutes they want, that could have a devastating effect.

“If you want to be cynical about the dollars and cents of it, there is a jeopardy for younger players as well, not just the coaches, referees and athletic staff.”

This is the great mystery about the coronavirus. 

“What everyone wants to know is how likely is it that an athlete would suffer long-term lung or other organ damage that jeopardizes their career,” Binney says. “My response to that is nobody on planet Earth, that we know of, has had this disease for more than seven months. It’s literally impossible for me to tell you that. I literally can’t tell you anything about what this disease does in a human body after seven months. That knowledge doesn’t exist in the universe.”

Binney adds that studies suggest that living on a ventilator for an extended period of time does have long-term negative impacts on the lungs and other organs of the body. While we don’t know what happens with coronavirus patients beyond seven months, we do know some of the life-saving treatments may have damaging ripple effects down the line. 

Finally, Gandhi mentions that blood clots also are a unique characteristic of COVID-19 compared to other infectious diseases, which is alarming for NBA players that already may be more susceptible to blood clots due to extensive air travel. Binney and Gandhi both agree that more research needs to be done to learn more about the long-term effects.

“The most important thing I want people to understand is how little we understand,” Binney says.

To that end, Gandhi offered a chilling send-off.

“We’re still very early in this pandemic,” Gandhi says. “It’s important that we be clear: we’re not bringing sports back because things are better now. We’re bringing sports back because we’re tired of not having them.”

Follow Tom Haberstroh on Twitter (@TomHaberstroh), and bookmark for my latest stories and videos and subscribe to the Habershow podcast.

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