With teams making their way into the Orlando bubble this week, the NBA is surely crossing its fingers, or perhaps even looking for some divine assistance.

“There are no atheists in the league office right now,” one team executive told NBC Sports.

Months of planning have led to this moment. All 22 teams have successfully arrived in Orlando. The early arrivers have started practicing and the others hope to follow shortly. Inter-squad scrimmages are set to begin in less than two weeks. The season officially resumes by the end of the month. It may be one of the most critical times in NBA history. 

If the coronavirus seeps into the Disney World campus and spreads throughout, the NBA will have no choice but to shut it down, commissioner Adam Silver confirmed on Tuesday. A shutdown could activate a force majeure clause in the collective bargaining agreement, negating the current CBA and leading to a potential work stoppage. Yes, the 2020-21 season could be in danger as well if this doesn’t work. 

With so much riding on this resumption, I spoke to  public health experts and epidemiologists about the core issues at stake with the NBA going to the bubble. 

Said Dr. Zachary Binney, an epidemiologist at Oxford College of Emory University: “If I was Adam Silver, I’d be white-knuckling it this week.”

Is the NBA being prioritized over the general population in a time of crisis?

The entire NBA operation sits on a foundation of daily testing and then processing results of those tests quickly. Early in the pandemic, the NBA was concerned about having enough tests to administer that daily regimen. While supply issues appear to have been resolved, processing those tests is not quite as simple.

Unlike Major League Baseball, so far teams have not seen significant delays or problems receiving test results, according to sources that spoke with NBC Sports. But there have been hiccups here and there. In the 24 hours before departure for Orlando, one NBA team had its tests accidentally sent to the wrong lab, according to league sources. The mistake forced the entire team to retake the coronavirus tests later in the day, delaying their trip to Orlando by several hours. 

“This is the new normal,” said one official of a team dealing with testing blips.

This space can be tricky at a time when the demand for tests is skyrocketing around the country and delays are becoming prevalent. The testing provider is central to everything. The NBA began using BioReference Laboratories to run their tests once they arrived in the bubble, sources told NBC Sports. That’s a different provider than their previous arrangement for in-market testing prior to the bubble. In the 113-page Health and Safety Protocol handbook distributed to teams last month, the league listed only one provider, Quest Diagnostics, as a preferred vendor. The league used Quest for the bulk of its tests around the country during Phases 2 and 3 of the resumption of the season. Phase 3, which is the transition into the bubble, concludes this Saturday, according to the document.

The shift away from Quest is notable considering that on Monday, Quest Diagnostics issued a worrisome press release. Quest stated a recent surge in demand for coronavirus testing had caused delays in processing, with 4-6 day average turnarounds on COVID-19 tests for populations that do not fall into their “Priority 1” group. That group includes “hospital patients, pre-operative patients in acute care settings and symptomatic healthcare workers.” Average turnarounds for Priority 1 would be one day, the lab company said.

It’s difficult to see how the NBA and its personnel would be considered Priority 1 in the Quest designation. Being put in the normal population group, with 4-6 day turnarounds, would lead to significant delays and could jeopardize the league’s entire testing operation.

“Let’s say you’re defending Stephen Curry,” Binney says. “If you take your eyes off Curry for one second, maybe you can still recover and stop him from scoring. But if you take your eyes off him for three seconds and you give him time to move around, he’s going to wreak havoc on you before you know what’s happened."

The hope for the NBA is that BioReference would be able to facilitate their testing in quicker order. So far, it looks promising. The MLS, a league that has also formed a closed campus on the Disney World resort in Orlando, is also using BioReference Laboratories for processing its results, per the official MLS website. MLS is facing issues of their own (more on that later), but it appears that testing delays aren’t one of them.

For folks inside the bubble trying to resume a professional sports season, that’s good news. 

But for those outside the bubble mired in a public health crisis, the swift processing for MLS and NBA may be problematic.

BioReference is experiencing serious delays with the general public. As of Thursday morning, patients attempting to access test results on the BioReference website would be met with an alert that reads: “If you are looking for your COVID-19 PCR (swab) results please note that these may not be available in the patient portal for up to 5-7 days after collection. As always, we appreciate your business and thank you for your patience during this unprecedented time.”

The local stories in Orlando involving BioReference are alarming. Last week, Central Florida’s CBS affiliate WKMG reported that a 74-year-old cancer survivor, along with several senior citizens at a nursing home, waited over a week for their results after being tested at the Orange County Convention Center (OCCC), one of the busiest testing sites in the state of Florida. The OCCC’s testing provider: BioReference.

In response to backlogs, the Florida Department of Health provided a statement confirming BioReference’s testing and that the state was informed by BioReference that the lab was experiencing serious nationwide delays. The state made the decision to switch from BioReference to a lab called Genetworx “to prevent a further delay in individuals receiving their results.”

A separate report from Orlando’s ABC affiliate WFTV9 confirmed the state chose to find reinforcements once BioReference saw widespread delays.

“In my professional opinion, and this is a personal opinion, a test that takes five days in infectious disease to come back, it becomes irrelevant,” Dr. Raul Pino, an Orange County health official, told WFTV9.

Sports leagues looking to get games going need quick turnaround times, much faster than a week. As of now, it appears that the MLS has jumped to the front of the line without issue.

“We are honored to be providing testing solutions to Major League Soccer as it prepares to restart its season,” said Jon R. Cohen, M.D., executive chairman of BioReference Laboratories said in a press release on Thursday. “The leadership of MLS worked diligently with us to develop a COVID-19 PCR and antibody testing strategy with the goal of providing the safest possible environment for the players, coaches and staff to begin to play again.”

For Dr. Binney, prioritizing sports leagues over the public health at a time when the virus is “exploding” is a troubling development.

“We should be thinking very, very carefully about whether that's something we want to be doing right now,” Binney said. “Diverting desperately needed testing capacity to support pro sports, which is what seems to be happening right now, is extremely questionable.”

The NBA has not officially announced their testing provider for the bubble and the Health and Safety Protocols document only mentions a provider (Quest) for Phases 2 and 3. For testing in Orlando, the document only says “All testing (through the duration of the season) will be conducted through a program coordinated by the league.”

It’s unclear if the NBA is being placed in a Priority 1 group or a similar class ahead of the general population. Dr. Angela Rasmussen, a Seattle-based virologist at the Center for Infection and Immunity at the Columbia University Mailman School of Public Health, expressed caution about using testing capacities for sports leagues.

“Certainly, we’re not in a good place (as a country), especially in the hardest hit areas,” says Rasmussen, a season-ticket holder for the NFL’s Seattle Seahawks. “And this is where, to me, the question of sports becomes an issue.

“At what point does it become unethical to reserve tests that would be available to the public otherwise for professional sports players just to facilitate having an NBA season? In Florida right now, that’s an especially relevant question.”

To Rasmussen, the optics of the NBA and MLS using BioReference as its provider while the general population waits on the sidelines is troublesome.

“You’re putting an additional burden on an already burdened testing system,” Rasmussen says. “That’s probably not going to go over very well from a public relations standpoint, at the very least.”

There are elements in the NBA’s resumption plans that could offer public health benefits. For one, the NBA and National Basketball Players Association (NBPA) have partnered on a research study using Yale University’s SalivaDirect test, which could have positive implications on the NBA’s future and the overall national public health. It is less invasive, less expensive and less taxing on healthcare workers, but the test needs more validation from a research standpoint.

The SalivaDirect test, which requires an individual to spit into a tube as opposed to using a nasal swab, would be secondary to the NBA’s testing protocol and it is not mandatory for players to participate. Rasmussen is hopeful that NBA players opt in.

“It has the potential to actually speed up the testing process and address some of these backlogs but not all of them,” Rasmussen says. “In my opinion, that’s what makes the NBA’s plan beneficial and kind of overrides any ethical concerns I have over, ‘Why are using these tests for professional athletes that don’t need to play?”

In addition to the Yale study, the NBA is planning to offer community testing, according to the Health and Safety Protocol handbook, but it’s unclear what form that takes.

For Binney, the moral quandary around testing should give the NBA serious pause about its plan.

“If BioReference or Quest is unable to return tests to the general public in less than 3-5 days, then I think the NBA (receiving priority) is causing a problem,” Binney says. “The NBA has only two choices. One is to jump to the front of the line with sick people in the hospital or they have to wait an unsatisfactory amount of time to get their results that gives the virus space to move throughout the bubble. Neither of those choices are acceptable.”

With the virus surging around the country and, more importantly for the NBA, in the Orlando area, the league could outsource its own partnered labs or own privatized lab for the general public.

“If you’re setting up your own internal lab, then the only question you really have is could the testing capacity you’re using for NBA players be more morally or ethically used elsewhere?” Binney asks. “Could you assist BioReference or Quest? Could you redirect all of that testing to the community rather than some of it? Is that something morally or ethically you have to do? I think that’s a value judgment. That’s a moral judgment.”

It remains to be seen where the NBA, which has at least $1 billion on the line, goes from here.

What about hospital and ICU beds in Orlando?

Beyond testing capacity, there is another critical issue in the NBA’s resumption. Hospital beds are filling up in the areas immediately surrounding the NBA bubble. If a player or staffer gets seriously ill or needs medical attention, where do they go?

A reporter posed that question to Silver, the league office and the NBPA on a call late last month. The NBA’s lawyer, David Weiss, stepped in and answered that the league will have an on-site clinic through the league’s partnership with AdventHealth.

“If someone gets sick and needs to go to that clinic, and needs to go to the hospital, they’ll be able to go to AdventHealth,” Weiss said.

What happens if that clinic isn’t equipped to deal with a specific injury or illness inside the bubble? In the two weeks since Weiss’ remarks, the situation around the bubble has turned grave.

Dozens of hospitals across the state have maxed out their ICU capacity. Locally in Orlando, it’s dire. As of Thursday morning, two local AdventHealth hospitals’ ICUs -- AdventHealth East Orlando and AdventHealth Winter Park -- have reached full capacity with 39 total beds filled, according to data from the Agency for Health Care Administration (AHCA). 

The largest AdventHealth hospital in the area, AdventHealth Orlando, is at 80 percent ICU capacity, with only 40 of its 191 beds open. Overall, Orange County hospitals are at 83 percent ICU capacity and 87 percent hospital bed capacity. 

Just as NBA players are flying into Orlando, hospitals are being pushed to the brink, AdventHealth included.

If the on-site clinic can’t handle an NBA-related emergency, does the NBA feel comfortable about taking a bed from someone in the general public?

“It’s not so much that everybody who gets COVID is going to die from it,” Rasmussen says, “it’s that when the hospitals are overwhelmed and there’s no place for people to go, more people are going to die that wouldn't have necessarily died otherwise.

If you have more people dying because they can’t get an ICU bed because they were in a car accident, or they can’t get on a ventilator because they had a severe asthma attack or bacterial pneumonia, then you’re going to see a lot of other deaths not because of COVID but because the hospital system being strained to the breaking point. That’s really, really scary.”

There’s another issue here. If AdventHealth has provided staffers, facilities and resources for the NBA and those resources are going unused in the bubble, can the NBA allocate those resources to the public?

“The idea of having an on-site clinic with Advent Health is in theory a great one,” Binney says. “It limits the number of times that players and staff can leave the bubble; You have everything they need inside the bubble. That’s admirable and that makes sense. The problem would be if you’re taking away resources from the community that are desperately needed to care for COVID-19 patients.”

Binney says there could be a time when the league should not have an on-campus clinic dedicated solely for NBA personnel. In April, nurses and doctors were flown across the country to New York City to assist overwhelmed hospitals. That moment could be coming for Florida. 

“We’re not there yet,” Binney says. “They’re trending in a very concerning direction, but they’re not there yet.”

Is the NBA quarantine long enough?

Putting aside the testing backlogs and dwindling hospital beds, there’s a third concern that the NBA has on its hands. Is the league’s opening quarantine enough to prevent an outbreak? 

Transporting and isolating hundreds of players and staff on over 20 teams into the bubble is an enormous operation. This is a critical juncture in the bubble’s efficacy. If one step isn’t done correctly along the way, an outbreak could sneak in.

The MLS found out the hard way that outbreaks are hard to keep out. On Wednesday, the league kicked off its “MLS Is Back” tournament without one of its clubs, FC Dallas, who was forced to withdraw from the tournament after 10 players and one coach tested positive for coronavirus. On Thursday, a second club, Nashville SC, was eliminated after at least nine players on its squad tested positive. 

How did that happen?

MLS had been testing players since early June, when training began in clubs’ home markets. The league then ramped up testing before departure on June 28. Prior to going to the MLS bubble, all personnel were required to complete two tests 24 hours apart within a 72-hour time period before traveling to Orlando. Upon arrival, another test was administered. Still, FC Dallas and Nashville SC brought infections to Orlando.

Again, how did that happen? The incubation period for coronavirus can last somewhere between 3 to 5 days, meaning that a person could be infected and not show enough virus load to test positive for several days.

Three weeks ago, in a correspondence for a different story, Binney outlined potential problems in the current entry quarantine protocol being used by the NBA and MLS. His thoughts turned out to be prescient. 

“Consider a player on the Houston Rockets and let’s say Houston is experiencing an explosive increase in cases,” Binney wrote in an email. “If Rockets players are living at home with their families, then you're relying on the honor system for both them and their families to really limit their time outside of the house. If they don't, there's a very real risk they could get sick just before they leave; that infection may not be picked up by pre-travel tests but could reveal itself in Orlando. 

Binney continued.

“To guard against this you could require players to move into a hotel in their home market and undergo daily testing a week before they leave to decrease the chance they pick up an infection right before traveling.”

Binney sent that email on June 16, a week before the NBA began testing players in-market (16 came back positive, with several more in the coming days). On June 16, Houston’s Harris County had seen a total of 17,282 cases in the prior three months since the first test, according to official state data. Three weeks later, the total is now 39,311, meaning that Houston cases doubled in that short amount of time. With Texas seeing a massive surge in cases, Binney’s example proved to be more applicable than he thought.

“I’m a scientist and so I try to be honest when I’m right and when I’m wrong,” Binney said over the phone this week. “When I wrote that email, I didn’t think (needing an airlock) was likely. I thought an airlock would be a nice addition, not a must-have.”

Binney has since changed his mind.

“But now, with the amount of virus circulating in so many places in the U.S. and we’re seeing twice now in MLS, how teams imported outbreaks into the bubble, that has made it clear to me that an airlock is far more important than I initially thought,” Binney said.

To protect against an outbreak being brought into the system, the NBA implemented a 36- to 48-hour quarantine in which the players and staff would have to return two negative tests spaced out by at least 24 hours. Then, they can resume practice and group workouts. 

To Binney, that’s not enough time to ensure as much as possible that the virus is at bay. As the MLS example showed, multiple tests over a three-day span weren’t sufficient in preventing at least two clubs from bringing the virus into the bubble.

The NBA and NBPA did not agree to any sort of in-market airlock system for its players in their home markets. In the health and safety guidelines, players and staffers participating in team activities were required to undergo coronavirus testing every other day starting July 1 and both of the two days prior to travel. 

“MLS has shown that the most delicate and tricky part is making sure everyone who's entering is uninfected,” Binney says. “We haven't seen any evidence of widespread within the MLS bubble yet, but we're not out of the danger zone at all. I'll be holding my breath for the first week or so after each NBA team enters the bubble.”

Binney’s colleague, Dr. Neel Gandhi -- an infectious disease expert and associate professor of Epidemiology at the Emory University Rollins School of Public Health -- thinks the situation has worsened just as the NBA needed it to improve. 

“We are pretty close to the worst-case scenario from the point of view of the surrounding community,” Gandhi says. “For me, we are getting close to as scary a place as we were in March. Back then, we didn’t know what we were fighting against. Now it worries me that we know, but many segments don't want to face up to that reality.”
 
The NBA shut down in March after one test, Utah’s Rudy Gobert, showed up positive. How much would it take before the NBA feels it needs to shut down operations again? In talking to Fortune, Silver would not say. But he did stress the importance of this quarantine period and right after it.
 
“It would be concerning if once (NBA players and staffers) sit through their quarantine period and then were to test positive, we would know that there is in essence a hole in our bubble. That our campus is not working in some way. That would be very concerning … Certainly, if we had any sort of significant spread at all within our campus, we would be shut down again.”
 
As the situation unravels outside of the bubble, the NBA awaits its results. Amid a global pandemic and testing crisis, the NBA certainly won’t be insulated from the environment around them. “If there’s any commissioner I trust to do the right thing,” Binney says. “It’s Adam Silver.”

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