Los Angeles Dodgers reliever Scott Alexander, who has diabetes, has consulted with doctors for advice on his situation should Major League Baseball resume. (Aaron Gash/AP)

The messages started piling up in Scott Alexander’s phone, links to studies and news articles sent by friends and family. They detailed the possible links between diabetes and dangerous complications from the novel coronavirus because of how elevated blood sugar can suppress the immune system.

Alexander, a reliever for the Los Angeles Dodgers who has diabetes, had not worried about placing himself at higher risk than any of his teammates if he returned to baseball. But he called the Dodgers’ doctors to ask for advice.

“All the conversations that I’ve had with our medical staff and our team doctors have basically said that as long as I do what I would normally do as far as keeping myself healthy, they said that I wasn’t really at any higher risk than any other person,” Alexander said. “That’s kind of been my mind-set. I trust what they’re saying. I know this is an ever-evolving situation.”

Alexander is in a class of professional athletes that adds a layer of complication and caution to the already dizzying task of sports leagues returning to play. Young and in peak physical condition, athletes are in the demographic least likely to face severe effects even if infected by the coronavirus. But among them are cancer survivors, diabetics, sufferers of autoimmune diseases and other immunocompromised players who may be at greater risk of catching the virus or more susceptible to the worst of covid-19, the disease it causes.

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There may be only a handful of players who face potentially elevated health risks in each sport. But the leagues must handle them as a crucial component of return-to-play plans because the stakes for them could be literally life and death. Leagues and players’ unions also must come to an agreement on how players who might opt out for health reasons should be handled from contractual and roster standpoints. Would they be placed on injured lists? Denied salaries? Those are issues leagues have yet to sort through.

“People see professional athletes as these kind of invincible robots where they’re always in the best shape and there’s no kind of chink in their armor, but that’s not really the case,” Cleveland Browns offensive lineman and NFL Players Association president JC Tretter said this month in a conference call with reporters. “There are a lot of guys with underlying conditions and problems that we have to look out for. That’s something we’re always trying to keep top of mind.”

Athletes with health issues who have spoken publicly have said almost uniformly they plan to play and don’t feel endangered. Still, as potential start dates near, they will be faced with a difficult final choice.

“That would be a heavy decision,” said retired NFL linebacker Mark Herzlich, who spent seven seasons in the league after undergoing treatments for a rare form of bone cancer in college. “It will eventually be a heavy decision for whoever has to make that.”

No two situations alike

Health experts say there’s not one easy answer. For starters, data on how much more at risk immunocompromised people are to the coronavirus is still emerging. “Anybody who tells you right now, ‘I have an answer,’ beware,” Stanford infectious-disease doctor Anne Liu said. The range of preexisting conditions is huge, and even within the same condition, severity and risk differ greatly. Liu said athletes would need to take into account what sport they play, whether it’s indoors and what protocols are in place.

As one example of how clouded it can be, some experts have speculated immunocompromising medications might be protective, and some of those medications are even being tested as part of covid-19 treatment. But Liu thinks the low percentages are resulting from those patients being more willing to take precautions to the extreme, having lived with social distancing under normal circumstances to protect themselves.

Testing will be crucial, Liu said. A reliable and fast test for a large gathering of people, such as a sports team, is not readily available. Even the Abbott machines the White House uses have shown inconsistencies, Liu noted. But that level of testing could be available in a few months, if not sooner.

“The more immunocompromised an athlete is and the higher level of contact that sport is, the longer I would want that person to wait until there are good testing protocols in place for screening large groups of people,” Liu said.

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“How can we say it’s not safe for fans to sit in the stadium but it’s safe for players to sweat on and hit each other?” said Herzlich, who cycled off the NFLPA’s executive board in March. “No one is spitting on each other on purpose, but spit flies. It’s kind of a gruesome sport in that sense. The idea would be that players have to be tested.”

Major League Baseball and its players’ union are engaged in a tense standoff over player salaries. One person familiar with the negotiations said the issue of players with preexisting conditions would be an important piece of negotiating. MLB and the union would need to agree on whether a player who opts not to play over a health concern would accrue service time and how much of his salary he would receive. In an interview this month with CNN, Commissioner Rob Manfred expressed sensitivity to the issue of players who could face elevated risk.

“If I can play and it’s safe, I’m going to play,” Alexander said. “If they tell me it’s very dangerous, it doesn’t really matter what the service time or the money is. I’m only 30 years old. I want to live a long life.”

Alexander believes other players in his situation would choose health over money if faced with the choice.

“This one year doesn’t necessarily mean all or nothing,” Alexander said. “If someone does have a health issue and they’re still relatively young, they still have a future ahead of them. They don’t want to risk something that could compromise their future. That’s the way people make money and provide for their families. It’s a real thing.”

Cost analysis

The overwhelming desire among athletes to play is not a surprise. Professional athletes, almost by rule, will choose to play in the face of physical harm if allowed. But crashing into opponents with a compromised immune system is a different form of risk than gutting through the discomfort of a strained muscle. Leagues or team medical personnel may have to take a prominent role in deciding whether an at-risk player should stay home.

How to handle a player with a preexisting condition is one of myriad issues the NBA and the NBA Players Association are still working through as they aim for a return. Given Commissioner Adam Silver’s player-friendly history, it is unlikely the league will haggle over the salary of an immunocompromised player.

Cleveland Cavaliers forward Larry Nance Jr. has Crohn’s disease, which causes inflammation of the digestive tract. Medication for the ailment can suppress the immune system. Nance said he desperately wants to return to play but only after he feels assured the conditions will be safe.

“It's definitely something that would have to be addressed thoroughly before I consider subjecting myself to that many people, whether it would be thorough testing or an absolute lockdown at a site,” Nance said on a conference call with Cleveland reporters.

For many fans, the absence of sports feels like a loss. Psychologists say that’s normal.

Pittsburgh Steelers running back James Conner was diagnosed with Hodgkin’s lymphoma in 2015 and underwent successful treatment while in college. He said his health history would have no bearing on his playing status, because doctors told him enough time has passed since his treatments.

“I’m so far removed from that, going on four years now,” Conner said on “The Adam Schefter Podcast.” “So just talking with my doctor and having a great relationship with him, he said you got nothing to worry about as far as your immune system or anything like that. I have no concerns with that.”

In the NFL, some players have “splits” in their contract that pay them a percentage of their salary if they land on injured reserve. Herzlich said he would worry about players being financially incentivized to play despite higher risks of complications should they become infected with the coronavirus.

“Making half of your salary because someone else told you you had to put your body at risk, that’s a decision that needs to be made beforehand,” Herzlich said. “The worst case is someone contracting the disease who has an immune deficiency and then being seriously hospitalized. That’s the thing that nobody wants to see happen.”

For now, Alexander is preparing as normally as he can, monitoring his glucose levels as he always would. Dodger Stadium recently opened for limited workouts, and Alexander has been going. He receives a temperature check and a pulse reading upon entering. Two teammates are in the stadium with him at a time, but he never even sees them. Players rotate through stations — 40 minutes on the field, 40 minutes in the weight room, 40 minutes in the training room. Despite the oddity, Alexander cherished standing on the sun-drenched field.

“If I were to get a phone call saying, hey, new information’s come out that says that you are really at risk or it could be fatal, obviously I would have to think about it again,” Alexander said. “As of right now, I’m just going with what they tell me and preparing. I trust them. If they tell me that it’s safe for me to do this, I believe them. I don’t think they would put me in any situation where I would be in danger.”

Coronavirus: What you need to know

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