Bubble jeopardy: Cricket's new normal

In any other year, Dr Shuaib Manjra's time would be divided between his role as Cricket South Africa's chief medical officer and his own private practice. Dr Manjra specialises in sports medicine and occupational medicine, an appropriate skill base from which to treat cricket injuries and figure out how to manage player workloads. There were times over the past decade when cases arose that were around the edges of that speciality - when a bail in the eye ended Mark Boucher's career in 2012, Dr Manjra found himself escorting the wicketkeeper between ophthalmology experts - but most of the work for CSA has revolved around more regular injuries. Until this year, that is.

"It's been pretty much full time for CSA over the past few months," Dr Manjra says. "Fortunately I have partners in my private practice who are able to share the burden, and clients who have been understanding of my availability - or non-availability, to be more precise - particularly during my times in the bio-bubble."

Medical officers such as Dr Manjra faced a new set of questions about how to keep their players fit and healthy as Covid-19 spread this year, the pre-eminent concern being what might happen to Covid-positive athletes exerting themselves to the maximum. "We didn't know what the impact would be on the heart, on the lungs, on the muscles. It could potentially have endangered the lives of players," he says. Yet the biggest task would come in establishing bio-safe environments (BSEs), the undoubted phenomenon of the year as far as cricket was concerned. The game could not go on without them, but creating a bubble required meticulous planning, huge financial investment, and ultimately some luck. It also involved making sense of a virus that nobody fully understood.

"We knew so little about Covid and yet we had to try and manage it and make serious decisions around it. We just have to do enormous amounts of reading," Dr Manjra reflects. It wasn't as simple as just doing the reading either. "If you look at normal academic journals, it would usually take them four or five months to publish an article. But during Covid, because of the challenges and because information needed to get out there quickly, things were being fast-tracked and journals were publishing things in a week or two weeks. So some things were peer-reviewed and some were not, and you had to read all of that stuff and then sift out the relevant information and figure out what's true and what's not true.

"There's lots of fake news out there. Everyone is reading all kinds of stuff and dealing with information and misinformation, trying to sift through it as stuff comes out on a daily basis. And some of the findings are changing - there will be something that comes out now, and then in a couple of weeks something else comes out about it that is completely different. It's been an enormous learning experience, picking through it and then putting it into practice, and it's not always easy to put it into practice."

The difficulties of creating and maintaining a bubble became apparent during England's tour to South Africa, when the ODI component of the tour was called off in the wake of a string of positive tests. Two Proteas players sat out the three T20s after testing positive soon after their entry into the bubble, but it was a third positive test among the hosts between the T20 and ODI series that caused real challenges. Two hotel workers and two England players subsequently tested positive. Neither of the hotel workers had left the hotel premises in weeks, they hadn't been in contact with each other or with any of the Proteas players that had tested positive, and none of the people they had been working with tested positive. Further testing suggested that they had come into the hotel with Covid, but had tested negative in their original PCR test. The English cricketers, meanwhile, proved to be 'false positives'. All of which highlights how unreliable the PCR test - on which so much of the world's Covid narrative is based - can be, and also how a simple cricket tour can turn into an expensive detective exercise.

"I didn't go into the bubble expecting zero positives, I went in expecting positives and saying how do we manage them," Dr Manjra says. "That's what our protocols are based around: how do you manage positives? I look back and see we had positive cases and try to think what we could have done differently, but I actually don't know. Maybe a little bit more testing, more stringent lockdowns of the players, but I don't know if it would have changed the outcome."

Over the course of its summer, the England Cricket Board carried out 10,000 tests on men and women players - and that was just for its internationals. In a similar vein, players at the IPL were tested every three days. "That's probably your best guarantee," Dr Manjra says, while pointing out that these measures come at significant cost. Because PCR tests alone are not enough, medical teams in charge of the bubbles follow an exhaustive process to try and build a fuller story.

"Is the Covid (PCR) test positive or negative? What is the Cycle Threshold (CT) score? And then we look at antibody levels. This is all to try and figure out whether it's a true positive or a false positive and where the person is sitting in the cycle of the disease," explains Dr Manjra. "For example, you have a positive and so you do a CT score; 48 hours later you do a repeat of the PCR test with a CT score to figure out whether the bio-load is increasing or decreasing. That's how we try to filter false positives and false negatives, and try to extrapolate backwards to try and figure out where they might have contracted the disease - whether it was inside the bio-safe environment or outside. And having long conversations with virologists to try and understand some of the complexities around it. Even with all of these modalities we still sometimes don't have a final answer."

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All of which offers insight into the mechanical process of the bubble. But what about the humans inside it? "This whole thing has cast a spell over peoples' minds and taken a huge toll on their mental state," notes Dr Manjra. The anxiety among the players was what ultimately led CSA and the ECB to postpone the ODI series. Many of the English players had spent the better part of six months in bubbles, cut off from loved ones and often from each other. Around the time of the South Africa tour, Tom Curran and Tom Banton announced that they were pulling out of the Big Bash due to bubble fatigue - a decision that Jofra Archer had already taken back in September.

But the effects of bubbles are not just being felt by English players; they were the forerunners after being exposed to bubble life first, and others are now following - 10 West Indians have opted out of a tour of Bangladesh in January. "I missed out on the LPL but a part of me wasn't sad because I didn't know if I could do another 14 days of quarantine in the room just by myself," says Sikandar Raza Butt. "I don't know how many more I can do. I did it for the CPL, then I came back to Zimbabwe and did it here ahead of the Pakistan tour, then we had the Pakistan tour and there was a bubble there. We came back and started playing domestic cricket - again there was a bubble. I went home for a few days and now I'm going into a bubble again."

In November, Kagiso Rabada summed up the experience of living in a bio-bubble. "It's almost like a luxury prison that we're in," he said, and it's difficult to argue. "It's 14 days in your room, where you're not allowed to come outside your room," explains Raza. "Just a knock on the door for breakfast, lunch and dinner. There will be food outside your room, you pick it up, go back inside and eat. Afterwards you leave your tray outside. That's the only time you can open your door. For me it doesn't really matter how big the room is, it's just empty spaces and yourself alone.

"To be alone and not able to see family, it's one thing. But our tours used to be four weeks; now they're six weeks. Some countries you do a two-week quarantine before the tour, then you do the tour, then you have to come home and isolate and quarantine again. Believe me, it's not easy at all. I don't know what was harder for my mental health, that loss against the UAE (in 2018) that meant we didn't go to the World Cup, or bio-bubbles."

Given how tough the isolation experience can be, it is little wonder that reports of breaches permeated the news. Archer's trip home to see his dog in between Test matches was the most high profile, while Pakistan players were found sharing meals and mingling during their quarantine ahead of the New Zealand series. Other anecdotes show how, after serving their quarantine time, players can be so desperate to maintain the bubble that it can lead to farcical scenes.

During the IPL, the Delhi Capitals were staying in a separate wing of the hotel which constituted their bubble. The team owners were maintaining a similar bubble in the same hotel, but had guests who would come and go for the matches in Dubai. One day a guest who was familiar to the team was checking into the hotel when he spotted some of the players and promptly went up to say a simple hello. It resulted in team staff jumping up and fleeing helter-skelter in the lobby from the amiable guest, who was left a little puzzled by the scene until the magnitude of his actions dawned upon him.

Anxiety levels are clearly high enough, then, even when bubbles remain secure and the show goes on. But what about the times when things go wrong and players test positive? The case of Ruturaj Gaikwad, the Chennai Super Kings opening batsman, points to just how hard it can get. Gaikwad knew he would be spending seven days in mandatory isolation upon arrival in the UAE for the IPL. "The first three days of the mandatory isolation, it got to my head. I wanted to go out," he says. "But by the fourth day, it's just a matter of two more days and I'll be out."

Except that it wasn't. On the seventh day, the 23-year-old started feeling body pains. "I thought it was because I worked out a little more than the previous day," he says. But the next morning it was worse, and now there was a headache. Some of his teammates had recently tested positive, and Gaikwad began to accept that he had contracted Covid. When a test confirmed it, he was consigned to a further 14 days in his hotel room. Friends and family back home began to worry. "I assured them that I didn't have much of the symptoms and by the second or third day I was pretty relaxed. I just told them there was nothing to worry about and I was completely fine because even people aged 90 have recovered from the virus. After 10-12 days, they were a little bit relaxed. But the initial reaction was that they were very, very sad and very, very unhappy about it."

While Gaikwad was able to make peace with the situation, the next six weeks were rough. While in quarantine he switched off from cricket because he couldn't bear the thought that others were out there playing while he was stuck in his hotel room. Unable to train properly and feeling demotivated, a "little bit of yoga" was all that he could muster. After 22 days in quarantine he finally emerged on September 19, the day the IPL started, and practised the following day. On September 22, he was drafted into Chennai's middle order because of an injury. "I went in with a very positive thought that I had scored really well in the domestic circuit and I was pretty confident, even though I hadn't played for so long," he says. Coming in at 77 for three in a tall chase against Rajasthan Royals, Gaikwad registered a first-ball duck. Three days later he made five from 10 deliveries against Delhi before being run out. He didn't play again for another month.

By that point, Chennai were out of the reckoning for the playoffs and so, despite recording another duck on his return, the team management gave Gaikwad an extended run. The time off the field had allowed him some perspective. "I realised that I was expecting too much from myself. Obviously many players coming to a tournament like IPL will practice for 2000-3000 balls. I hadn't done any of that and I was just stuck in quarantine, so I had to accept the fact and that even if I didn't perform this year, it was fine."

He finished the tournament with scores of 65 not out, 72 and 62 not out, and with coach Stephen Fleming and captain MS Dhoni admitting that Gaikwad had been rushed into action too soon after quarantine. It is a story that speaks not only of the mental health challenges of the year, but also that our expectations of players to perform to previous levels under this new set of conditions is unrealistic.

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So what about 2021?

"What I'm seeing now is a scary scenario," says Dr Manjra. He points to South Africa's rocketing Covid numbers and a packed Proteas schedule, and says the only way to make this work with the endless bio-bubbles will be to rotate players and support staff endlessly. Because as successful as bubbles have been in some parts of the world, the toll on the players was already showing in November. "Even England would concede it's not a sustainable proposition because it's hugely costly and takes a lot of manpower," Dr Manjra says of bio-bubbles. "It even takes a mental strain on players because they're locked down for long periods of time. Part of England's conditions when they came here was to allow some kind of freedom - golf - because players needed some mental release."

The cost of running BSEs has already driven a wedge into existing inequalities in the world game. The ECB spent more than 10 million pounds on Covid measures during their home summer, which was only possible because their broadcast rights ran into hundreds of millions. Yet most cricket nations were already losing money on most of their inbound tours before Covid, making the cost of bio-bubbles a loss-extending exercise. New Zealand Cricket budgeted more than NZD 2 million for the quarantining processes necessary to host international cricket this summer - an amount that can be the difference between smaller boards making a profit or a loss for the year. It is no coincidence that international cricket clustered in the wealthiest nations during the second half of 2020.

Everyone else may need to wait for a shift in global events before any sort of normal schedule can resume. The effect that vaccines will have remains to be seen, but of course they are being rolled out in wealthier nations first while others might not have access until 2022. Hopes of growing immunity are equally uncertain as the virus mutates.

"In jest I was saying that there would be a time when all of our players would have tested positive at some point, which would give us some kind of a showing that people had antibodies and some sort of immunity against the disease," says Dr Manjra. "I said that until we began to see these new forms of the virus emerging, which raise the question whether you have protection against these mutations. Previously if you had someone recover from a positive test, you had some degree of comfort that there would be some degree of immunity, but now you're not so sure.

"I don't know where this thing is going to go. How long it's going to last, I don't know."

With inputs from Prakash Govindasreenivasan