“Football unites the world,” soccer’s global governing body, the International Federation of Association Football (FIFA), proudly declares. But this summer’s men’s World Cup kicked off with geopolitical tensions on display. To add to the challenge, this is the most complex World Cup ever, with three host countries and an expanded roster of 48 teams. Three-quarters of the 104 matches are being played in 11 U.S. cities. To gain insight into the health and security challenges of this World Cup, I spoke with an internationally recognized expert in emergency medicine and major-event care.

Dr. Mick Molloy is a faculty emergency physician at University College, Dublin, Ireland. A formidable athlete before becoming a physician, he played Rugby at the national and International Level. He served as team physician for the Irish National Rugby League team at two World Cups and was Commissioner of Rugby League Ireland for six years. He’s managed medical care for more than 300 mass gatherings (many involving international soccer) and was Chief Medical Officer for two UEFA Conference League Finals.

Dr. Art Kellermann: Is the U.S. medically prepared for the World Cup?

Dr. Mick Molloy: This is the question of the moment. I had conversations with senior medical professionals preparing for this protracted competition. One of the challenges is whether America’s overstretched ERs and EMS personnel systems in host cities can sustain the substantial demands of covering multiple World Cup hotels, training facilities, fan zones, and other venues in addition to their existing 24/7 duties.

For example, some of the medical planners I spoke with did not initially realize that the fan zones must be supported throughout the 30 days of competition. They assumed that they’d only be operational on local match days.

The Scale Of This World Cup Is Unprecedented

Dr. Kellermann: We’ve hosted big international sports events before, including the 1994 FIFA Men’s World Cup, the 1999 and 2003 Women's World Cups, and eight Olympic Games. Isn’t that proof that we know what we’re doing?

Dr. Mick Molloy: It has been a long time since the U.S. hosted the FIFA men’s World Cup, which is bigger and lasts longer than the Olympics. Add to that the tension involved when certain countries meet on the field, particularly in the knockout stage of the competition. Iran’s team is competing, though its participation is fraught with geopolitical tension. And this World Cup could be complicated by the presence of masked ICE agents.

In previous World Cups, teams were usually guaranteed a swift immigration process. Unfortunately, that was not the case this time. I saw images of teams being screened in open air, news reports of official delegates being refused entry, and even a World Cup referee from Somalia being turned away at Miami International Airport. Media in Europe reported on fans who’d secured an ESTA (Electronic System for Travel Authorization) waiver for entry into the U.S. months ago, only to find in the week before travel that their status had been changed to “pending” or “rejected.”

Issues of Concern

Dr. Kellermann: What worries you most?

Dr. Molloy: For players, it’s the heat. FIFA and its medical department work with team physicians to prepare them for the weather conditions they may expect in the host country, but the unpredictable element here is the playoff nature of the competition. Advancing teams may play in a city where they have little time to acclimatize. There will be hydration breaks during games and special rules that take effect if the on-field temperature exceeds 32°C (90°F).

Fan health is also a concern, as many fans will spend extended time in the summer heat. In heat waves, Aid stations could be hard-pressed to manage everyone affected.

Fan fights are another worry. In most parts of the world, soccer and alcohol go hand-in-hand. Some of the competing teams have a history of bad blood between their fans. So far, crowd moods have been good, but tempers rise in the knockout stage of the competition. At that point, team combinations won’t be known until the last minute. Host cities will have little time to organize added security for games with volatile pairings.

The fan zones could be challenging. Because they are free and show non-local matches on massive screens, they could get very busy. European club football (e.g., Premier League) establishes separate fan zones for supporters of rival teams so they don’t interact in an alcohol-fuelled environment. That’s not feasible in a 48-team World Cup. Medical and security personnel must be vigilant throughout the competition

ICE agents are maintaining a visible presence. U.S. officials emphasize that they are focused on event security rather than on immigration sweeps. I worry, however, that if adverse interactions occur, things might spin out of control. If word spreads that ICE is conducting searches or arresting fans, it could spark protests and increase the risk of violence or a deadly crowd crush. This concern also applies to fan zones. I hope that common sense prevails.

Security

Dr. Kellermann: How does stadium security factor in?

Dr. Molloy: Crowd management is a concern at any mass gathering. The fan violence that was a part of global soccer in the 1970s and 80s has almost been eliminated, but it can still raise its head,

In stadiums, conflicts can be reduced by keeping fans of teams with antagonistic histories apart. In many European countries, police accompany each team’s supporters along pre-designated routes to the stadium to avoid the other team’s supporters. I don’t think this is done in the United States.

When the World Cup enters the knockout phase on June 28, emotions will run high. Given soccer’s history and current international tensions, crowds should be carefully managed throughout the competition.

In the UK, programmable signs direct crowds to the stadium with voice and text messages that are translated into the languages of expected fans. They are also helpful in emergencies, such as a suddenly hostile crowd or a disaster situation. I am unaware if this technology is used in the United States.

Modern stadiums are designed to minimize the risk of crowd crush, but it is hard to eliminate the possibility. “Nozzle effects” occur when two or more streams of people meet at angles in an insufficient space. When a crowd has a singular focus of reaching their seats on time, it can lead to dangerous behavior. This must be avoided at all costs.

It will be important to actively monitor crowd density at key places and intervene if it grows too quickly. Otherwise, falls, trampling, injuries and deaths could occur.

Aggressive Fans

Dr. Kellermann: FIFA expects over 6.5 million spectators. Most will be domestic rather than international travelers. Does that mitigate your concerns?

Dr. Molloy:

Not really. Because passions run high in soccer, supporters of competing teams should be seated in different areas. If fans of team one end up in a crowd supporting team two, it could cause security challenges. The stakes grow in the knockout round.

Fans from competing nations purchased tickets in advance to guarantee entry to the stadiums. So did domestic fans with ties to competing countries. Given ticket costs and last-minute visa challenges, reselling is inevitable. So any plan to keep the supporters of rival teams apart will be imperfect.

Hopefully, all will go well. However, in mass-gathering healthcare, it’s better to anticipate worst-case scenarios and engineer solutions in advance rather than wait and react.

Closing Thoughts

Dr. Kellermann: The World Cup is underway. Do you have any parting words for those in host cities who are responsible for dealing with health and security risks?

Dr. Molloy: World Cups are full of joy for many and sadness for others. Inevitably, some will become overwhelmed and need support. Please remember that due to language barriers, these individuals may not understand questions or commands from the police. Festina Lente – balance urgency with diligence and decisiveness with compassion to ensure that those who require care get the treatment they need.

Bill Shankley, a Scottish player and manager who transformed Liverpool F.C. from a struggling second-division team into a European powerhouse, famously remarked, ”Some people believe football is a matter of life and death… I can assure you it is much, much more important than that.”

This article was originally published on Forbes.com