She blacked out at World Championships. Now swimmer Anita Alvarez makes a comeback

On Thursday, artistic swimmer Anita Alvarez will compete for the first time in nine months. Last June, at the World Aquatics Championships in Budapest, Hungary, the two-time Olympian finished her free solo routine, passed out, and sunk to the bottom of the pool.

Team USA head coach Andrea Fuentes dove in, fully clothed, and saved her.

Horrifying photos ricocheted around the world.

Since that viral moment, Alvarez, 26, has grasped for answers, chiefly: Why did it happen – not once but twice? (In 2021, at an Olympic qualifying event in Barcelona, Alvarez lost consciousness after her duet and Fuentes pulled her to safety.) Was she okay? Did she want to compete? Would the U.S. team let her compete? Would World Aquatics, allow it? (The sport's international governing body already faced scrutiny in 2010, when American swimmer Fran Crippen died in a 10-kilometer race near Dubai.) Friends and family asked questions Alvarez couldn't answer. On top of that, there were critics.

As a result, Alvarez hasn't spoken extensively since the event on June 22, 2022.

Until now.

Alvarez tells NPR in an exclusive interview she's confident about returning to competition

In an exclusive in-depth interview, her first since Budapest, Alvarez says, "I feel very confident" heading into the World Cup season opener in Markham, Canada (near Toronto). She had just finished six hours of pool training with a half-hour break. Her diagnosis remained private, but she gave detailed accounts of both incidents and what she's learned during her comeback.

She recounts from June 12, 2021 when Barcelona hosted the last-chance qualifier for the Tokyo Olympics. The U.S. had just missed a team berth by two-tenths of a point, and it had been a late night. On the morning of the free duet prelims, the New York native says she felt "a bit more tired than normal.

"I remember getting to the end of the routine and not feeling like I had much control," Alvarez says. "I hit the last pose and I remember feeling like I was in a hamster wheel. Everything was spinning, then went dark. I woke up at the side of the pool and realized I'm at a competition. 'Wait, I am the competition.' Everyone's staring at me."

That night, Alvarez returned for the technical portion of the duet and put herself in a good position to qualify for an Olympic spot. It was her fifth of six events. For the free program final, "We thought it would be best for me to rest," she says, so the alternate stepped in the next day and secured Alvarez's duet spot for Tokyo.

"I started to get some testing after Barcelona to figure it out," she says, "but Tokyo came up so fast, and I don't think I did the best job of being on top of it."

After the Olympics, she took her first break in nine years and assumed the cause was burnout: "Mentally, physically, and emotionally. There was nothing major in the tests, so I kept going. Everything was fine until Budapest. I never even thought about the possibility of it happening again."

June 22, 2022 — the day she blacked out at the World Championships

In Budapest, Alvarez arrived for the free solo event – her seventh of eight events, and her second World Championship event of the day. After breaking her foot earlier in the year, she says she was, "for the first time in a while, really enjoying a competition. I had energy. I was giving everything, and had more to give. I was performing – really performing. All the way to the end, I felt strong."

Once again, the last pose was a snappy flip from upside-down to right-side-up with her head back. "That hard stop – that's when everything went a little dark," she says. "That's the last thing I remember until I woke up."

Her mother, Karen Alvarez, was watching at work, at a high school in upstate New York. Karen had coached a local artistic swimming team just outside of Buffalo for 36 years. "I knew something was going on," she says, "because they showed expressions of the fans and coaches." A Team USA representative called to tell her Anita was okay.

Meanwhile, Anita rested on a bed by the pool, and got in the water to shake out her legs. "I was exhausted, like I could sleep for five days," she says, but images revealed no water in her lungs. "Everything looked great."

The next morning, however, the photos went viral.

"I flip on the TV," her mother says, "and my phone starts going crazy because it was everywhere. The photos were hard to digest. I didn't think that would be the situation – of her at the bottom of the pool."

Her mother knew she had passed out before, but hadn't personally seen it during Anita's career which began at age 5. Anita had no history of asthma, diabetes, heart condition – not even allergies, her mother says.

Anita still had one more event: the team final two days later. "I was feeling better," she says, and the team routine is often easier than duets and solos. Also, she was the flyer, on top of all the lifts, and the team hadn't really practiced with another swimmer in that position. So Alvarez went to the pool that morning, gelled her hair and prepared to compete, but there had been a meeting in her absence, and she was told no-go. During the final, she stood on the pool deck, hair still gelled, watching the U.S. finish ninth of 12 teams.

Back in the U.S., the news triggered a bombardment of emails and Twitter messages. "My athlete had this ... My daughter had that ... I'm an expert ... Make sure to get this checked." The theory-and malady-catalog was overwhelming.

"I would Google each one, of course, a disease comes up, and you freak out a little bit. I had to go back to trusting my medical team looking into everything we can," Anita says.

Months of extensive testing

That meant months of extensive testing: cardiology, neurology, bloodwork. None as harrowing as on Oct. 14, 2022 in the UCLA pool. The mission: not only re-create – but exceed – the physical stress of the Budapest incident while wearing monitors and being observed.

That meant head coach Andrea Fuentes, a four-time Olympic medalist from Spain, had to design the hardest practice of her life.

"The days before were very hard," Fuentes says. "We talked a lot to prepare mentally. Personally, I was scared. As a coach, you don't like to see your swimmers going through that. But the goal was: We cannot swim [or compete] unless we find out what happened. We had to do it."

The team had the option to watch. "We told them, if you want to leave, leave, because it's not gonna be easy," Fuentes says. But they all stayed. "Imagine, the whole team screaming, cheering her on, making her push harder because doctors told us: the harder she pushed the better. The goal is that she pass out so we can find out why. So hopefully she passes out. I was like, 'Are you sure?' It was a very, very intense day. I never had such a hard practice – never did such a hard practice" – both as a coach and athlete.

It was a full hour to 90 minutes, nonstop.

At the beginning, she did her World Championship routine – again and again and again. The doctor asked for a harder set. Fuentes asked Alvarez to swim at top speed for 25 meters followed by 25 meters underwater. "Keep going till you pass out! But she didn't pass out," Fuentes says. "I was like, 'Let's stop already. It cannot be any worse.' She was crying."

But Alvarez ratcheted up the intensity. The team roared, and she pushed harder. The cardiologist worked with Navy SEALs and told Fuentes that Alvarez's load was surpassing Navy SEALs'. Finally, the doctor said: "That's enough. We have what we need."

"It was an epic day," Fuentes says.

Cardiovascular issues were ruled out. Neurological issues had been ruled out earlier.

"That was a huge relief," Alvarez says. But mentally, she says, it was tough to regain the comfort and confidence to train at high-intensity. And she still had to answer to World Aquatics. Before Christmas, her medical team shared its findings via Zoom, then waited. And waited. "I wasn't really aware of what was needed for me to get back. I'm in the team routine so if I can't compete, the earlier we know, the better.

On March 6 she received final waiver from World Aquatics

On March 6, she received the final waiver from World Aquatics to sign, a three-page legal document required to compete.

To prevent another blackout, Alvarez checks her iron and hemoglobin levels every few months. If they're out of range, they can be managed and stabilized with diet or supplements.

Fortunately, it's simple – because artistic swimming just got harder. A new scoring system makes its international debut in Canada this week. It rewards difficulty by considering the time spent underwater and the number of movements performed during that time.

"It's gonna be more risky for everyone," Fuentes says. "More time underwater means less oxygen. But the problem isn't spending 16 seconds underwater. A lot of people can hold [their breath] 16 seconds underwater, but not with your heartbeat at 200 beats per minute – many, many times in a row while moving at your max [power], fighting against gravity, with three seconds to breathe before you get in again."

As a result, Alvarez says, "There are a few choreography things that I'm avoiding, like coming from underwater and whipping my head back on the final pose. Other movements include a certain range of motion with my neck. I also have more awareness of my breathing throughout the routine."

But Alvarez has no illusions. The photos are still online. "I've seen a lot of pictures since – and pictures of my teammates in the stands, which are the most upsetting to me – to see how scared they were and how much they cared.

"She's a very important person in the team, the sport, and the country"

"To have it blasted out there was a big deal," she says. Worse were the detractors who created their own narratives. "People were saying it wasn't right to glorify an athlete pushing her body that far and making the coach the hero because it never should have happened," she says. Yet marathon runners collapse and snowboarders have fractured their skulls in the name of innovation.

Others said it made the sport (formerly known as synchro/synchronized swimming) look bad. Parents won't want to let their kids do it because it's dangerous. "I've been working my whole career to make the sport more popular," Alvarez says, "and now people are telling me that I'm a bad example.

"You take every comment and start to overthink it. 'How can I make it right?' " The answer is: You can't. Not everyone will understand. Not everyone will be happy.

On the flip side, others claimed: The attention helped the sport because people finally recognized its difficulty. "Which is also true," she says.

What is the takeaway?

"To be honest, I'm still figuring that out," she says.

Lately, Alvarez has been paying close attention to other athletes whose injuries make global headlines, like Damar Hamlin, the Buffalo Bills safety who went into cardiac arrest during a game in January. "That resonated with me," she says. "I followed his story and how he dealt with that afterwards. It was interesting to watch a situation from the outside, seeing the media response, and how he handled it. Seeing it in the real world, in different situations, kind of helps me understand my situation a little bit better."

For now, all eyes are on the pool. The most important thing is to qualify the team for the 2024 Paris Olympics. This week is a start. Alvarez plays a key role.

"This is not going to stop her," the coach says. "She's following her passion. It's inspiring. I admire her a lot. She's a very important person in the team, the sport, and the country. She deserves the moment. We will qualify and get the gold. She deserves it more than anyone. She's been fighting a long time."

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