Paging Dr. Hamblin: Can We Sing?
Editor’s Note: Every Wednesday, James Hamblin takes questions from readers about health-related curiosities, concerns, and obsessions. Have one? Email him at firstname.lastname@example.org.
As we gradually reopen businesses, education, churches, etc., some questions arise. Is it safe for my friends who are music educators to teach choir in public schools, even with social-distancing practices in place? As churches open their doors, are they risking the safety of their congregants by singing together? Our church announced prior to this past Sunday that we would not be singing out of an abundance of caution. However, when we arrived we were told that if we were to sing, we should do so at a very quiet volume. Most people were either mouthing the words or barely producing sound when they sang.
A very general rule for minimizing the spread of any respiratory virus: Silence is safer than whispering. Whispering is safer than talking. Talking is safer than singing.
In the context of so much being shut down, the question of singing may sound trivial. But it’s not at all. Given that a huge portion of the world population regularly attends religious services, and that many services involve group singing, navigating this question is crucial for the year to come. Thousands of lives may hang on how it is done.
As the United States reopens, continued spread of the virus among some people—such as family members, roommates, or possibly co-workers—will be inevitable. What we can most hope to prevent are the “super-spreading” scenarios in which one person infects dozens of others. Choirs have repeatedly proved to be grounds for such events in the coronavirus pandemic.
The most infamous case was in Washington State, where one person attended a choir practice in early March while experiencing flu-like symptoms. Three weeks later, two fellow singers were dead. A subsequent study found that the “act of singing” contributed to 53 of the 61 choir members eventually testing positive. Around the same time, 102 of 130 members of an Amsterdam choir developed COVID-19 after a performance, and four people associated with the choir died. In Austria, 43 of 44 participants in a choir seminar tested positive. Similar super-spread choir outbreaks have been reported in South Korea and Germany. These events took place just before shutdowns went into effect. They will happen again, when shutdowns end.
With so much evidence now compiled, the simple answer to your question—don’t sing in groups—could seem obvious. In some places, leaders see it that way. Some parts of Germany, for example, have outlawed singing in churches. No law like that is forthcoming in the U.S., where churches are effectively exempt from much of the legal system. So decisions will largely be left up to local officials, individual congregations, and congregants.
The problem is, Americans don’t even have clear, uniform guidance for making such decisions, in part because the virus has become so politicized in the U.S. On May 22, the Centers for Disease Control and Prevention posted a warning on its website that deemed singing hazardous and recommended that congregations “consider suspending or at least decreasing use of choir/musical ensembles and congregant singing, chanting or reciting.” The next day, the agency deleted it after President Donald Trump deemed religious institutions “essential” and called on governors to reopen them. (The Washington Post reported that the White House instructed the CDC to delete the choir warning; neither the White House nor the CDC responded when I asked for comment.)
The government’s abdication of its duty to provide basic information on managing coronavirus risk is especially dangerous because, in addition to the documented super-spreading events, there’s clear physiologic reason to be concerned about singing—or chanting, yelling, wailing, or even wassailing. Doing so in proximity to other people, especially when airflow in a space is limited, is a pandemic nightmare scenario.
When you sing, microscopic particles burst forth from your mouth in a fountain of mist. Large droplets fall quickly to the ground, but the rush of air also creates an aerosolized mixture of everything that’s lingering in the mucus membrane of your pharynx. This is exactly where the coronavirus attaches and replicates, which it can do before a person feels any symptoms.
Once aerosolized, those tiny mucus particles can linger in the air for an hour or more and float farther than six feet. A normal exhale creates a little bit of aerosol output, but a cough or sneeze puts out a ton. Singing similarly puts force behind the excretion, shooting it out like a geyser. (The goal of singing, if I recall from my music education, is to “project.”) The exact danger of aerosolized virus remains unclear, but since choir rehearsals have proved so clearly risky, the safe default assumption at the moment is that these floating particles can get you sick. And while six feet is a typically cited safe distance to prevent viral transmission, you could assume that a sick person singing on the other side of a large room could infect you if you spend enough time listening.
Given the void of health recommendations from federal agencies on the subject of singing, musical organizations are stepping in and providing patchwork guidance. Last month, the National Association of Teachers of Singing, the American Choral Directors Association, Chorus America, the Barbershop Harmony Society, and the Performing Arts Medical Association hosted a joint webinar for choir directors, music educators, and performers on how dangerous group singing is in a pandemic. During the session, Donald Milton, an environmental-health professor at the University of Maryland, advised the groups not to gather again to sing in person until a vaccine or treatment for COVID-19 becomes widely available, even if that takes years.
This is the expert consensus, unfortunately. But the dangers don’t erase the fact that singing is integral to all sorts of cultural traditions, religious and otherwise, and a fundamental way of bonding, communicating, and expressing emotion. These things have value to human health that’s not as easy to measure as viral RNA, yet still demands to be taken seriously.
Like so many things, experts can’t offer a simple, permanent No or Yes, do it exactly like you always used to on the subject of pandemic singing. There may be some hope in the middle ground, where the risk is not zero, as it would be if everyone sang over Zoom in isolation chambers, but is still lower than traditional choral scenarios. Some groups have developed choral hacks like remote performances, or proposed amplifying clergy with microphones so they don’t have to project more than necessary. Churches that have the means could even, theoretically, be equipped with negative ventilation, which sucks air out of the space, like what hospital rooms have. Windows can be opened, crowds thinned, masks worn, and singing kept to a bare minimum. People can be rigorously tested (theoretically) to make sure that carriers of the virus come nowhere near the church. All of this, done together, would decrease the risks of super-spreading events.
A cheaper option is using nature to take services and rehearsals fully outdoors. This will be only a temporary fix in most places, because winter will bring its own challenges. And singing in the open air will fundamentally alter the effect: Sound waves will disperse instead of reverberating through an acoustically designed chamber. Whatever is lost in that experience for the congregation, there might be solace in remembering that the virus is dispersing into that air, as well. It’s not a zero-risk scenario, but we have every reason to believe it is safer than the old way.
As with everything in this fragile moment of reopening, the answer is going to be that the safest thing would be to never gather in groups for the foreseeable future. Short of that, the more preventive work that can be done, the better. Much of that work will seriously detract from the traditional worship experience. It’s a moment for creativity and openness to carrying on the spirit of the endeavor in new ways that, by their conscientiousness, will carry special significance.
Paging Dr. Hamblin is for informational purposes only, does not constitute medical advice, and is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. By submitting a letter, you are agreeing to let The Atlantic use it—in part or in full—and we may edit it for length and/or clarity.