By George Delgado, M.D.
Of all the activities that have been restricted by governors, mayors and health departments only religious gatherings are specifically protected in the Constitution. The First Amendment protects us from laws interfering with the free exercise of religion.
Unfortunately, some policymakers out of fear, disdain or hubris have overlooked the importance of the First Amendment and some have deemed religious worship “nonessential.” Fortunately, many religious communities are pushing back against the affront to the God-given right to religious liberty that is guaranteed by the First Amendment. I have been associated with legal teams seeking to overturn restrictions in New York State, California, Illinois and Delaware. So far, most judges are in agreement that states and counties have overstepped their bounds in placing unreasonable restrictions on religious bodies.
In the clinical practice of medicine, we acknowledge that people have spiritual, psychological and physical dimensions. We know that spiritual and psychological stress and trauma can lead to physical problems, including immune system dysfunction. Arbitrarily declaring religious services to be nonessential, besides being unconstitutional, also carries with it certain profound spiritual and psychological risks that, ironically, could actually lead to an increase in mortality from COVID-19 by negatively impacting immune function and by destabilizing the support systems of vulnerable people.
According to Robert Redfield, MD, the director of Centers for Disease Control and Prevention (CDC), at this point in the pandemic, both suicides and drug overdose deaths are outnumbering deaths due to the coronavirus, itself.  The social side effects of mitigation measures are rearing their ugly head.
It is clear that due to early mitigation measures carried out throughout the United States, the trajectory of the COVID-19 pandemic was altered; the “curve was flattened.” Mitigation measures, like any medical treatment, have untoward consequences, some foreseeable, some not. Furthermore, the “treatment” that got us to where we are now, is not the “treatment” that is indicated for us now.
The Reproduction number (Rt) is a measure of how much spread is occurring. When the Rt is one, on average, each person with COVID-19 will spread it to one other person — the pandemic is stable. If Rt is greater than one, the pandemic is increasing; if the Rt is less than one, it is losing steam. According to rt.live, the Rt is less than one in most of the country. See the graph, from rt.live, below, where green indicates the states where Rt is less than one. 
Many state and federal officials have expressed concern that religious gatherings pose an increased risk of the spread of COVID-19. Often, they provide no substantiation for their statements, only oft repeated half-true narratives propagated by the mainstream media outlets. In reality, religious gatherings are no more dangerous than other gatherings and are likely safer than social gatherings like family parties and those in bars where people are standing very close together, talking loudly and possibly imbibing alcohol. Certainly, they are safer than protests and riots that have been allowed and or tolerated in many cities.
One of the reasons some have expressed concern that worship services could become hotbeds of COVID-19 contagion is the well-publicized case in Washington State last March where, out of 61 attendees, up to 53 people became ill after a two-and-a-half hour choir practice where they were exposed to a person who was ill but did not realize he had COVID-19. Thirty three of those who were ill had tests confirming they were infected with SARS-CoV-2.  The participants were in a relatively small room with poor ventilation. Much of the time, they were only seated 6-10 inches a part. They practiced for two and a half hours and shared food, afterwards. Patient zero knew he was sick. Clearly, this is not how religious services are being conducted, these days.
Because of the Washington State case, some policymakers have justified their restrictions on religious gatherings expressing fear that singing, which is often part of worship services, increases respiratory droplets and aerosols thus making the public health risks of religious worship unacceptable. Some have quoted a webinar produced in May and sponsored by the National Association of Teachers of Singing and other groups that left viewers with the unequivocal message that singing with others could not safely resume until a SARS-CoV-2 vaccine or effective therapeutics were available.  Unfortunately the fear-based conclusion was not grounded in scientific evidence, as Naunheim et al. assert in the Journal of Voice. 
Singing does present some challenges; however, none of them are insurmountable. A comprehensive report produced by a collaboration between a university and three music institutes in Germany, titled “Risk Assessment of a Coronavirus Infection in the Field of Music,” was updated in July.  Citing research conducted by them and others, the medical, engineering and vocal experts conclude that singing only slightly increases the dispersion of respiratory droplets. It can, however, increase the production of aerosol particles, which are smaller (<5 microns). The group concludes that singing can safely take place in houses of worship, providing that singers be spaced about two meters (close to our standard of six feet), that masks be worn and that ventilation be adequate.
Both the German group and the article by Naunheim et al. emphasize that as spacing increases and the amount of time spent singing decreases, the risk of spread of the virus diminishes. Worship services generally have songs interspersed with sermons and prayers. The breaks in the singing allow droplets to fall to the ground and aerosols to be dispersed and diluted.
How many COVID-19 cases have been linked to houses of worship? A New York Times investigative report examined church-related outbreaks (and we can be sure they searched far and wide). “More than 650 coronavirus cases have been linked to nearly 40 churches and religious events across the United States since the beginning of the pandemic . . . “  However, to put the cases in perspective, one must divide the 650 confirmed cases related to religious events by the number of cumulative, confirmed COVID-19 cases on 10 July (3,038,325, according to Statista).  The calculation reveals that on 10 July, only 0.02% of the total US cases were related to religious event exposures. Indeed, houses of worship have been unfairly vilified across the country.
Additionally, it is important to know the number of people who normally attend religious services, regularly. According to Statista, in 2019 approximately 90 million American adults attended religious services, at least monthly.  The denominator is very large.
Public health officials have cited several cases to support their restrictions of religious liberty. A Butte County, California case has been brought forward as an “outbreak” because two people were purportedly infected with the coronavirus at a church service.  While two infected out of 180 is technically an outbreak, the infection rate of 2/180 or 1.1% certainly is not earth shattering.
There was an Arkansas church-related outbreak where 35 of 92 attendees developed COVID-19.  This case is clearly not a good comparator for much of the country.
- The outbreak occurred at a small rural church in Arkansas, not in a spacious building, like those where many Americans participate in services.
- The outbreak occurred early in the pandemic, before the national lockdown. Attendees were probably not aware of any precautions to take to avoid contracting COVID-19. Furthermore, the Rt was likely very high at the time.
- Rural Arkansans may be much less healthy compared to the typical attendees at church services throughout the nation. Arkansas has the third-highest obesity (a major COVID-19 risk factor) rate in the country , the third highest rate of hypertension (a known COVID-19 risk factor) in the nation  and the fifth highest rate of smoking among its residents. 
Those wishing to restrict religious services point to First Baptist Church of Tillmans Corner in Mobile, Alabama, which resumed in-person services on May 17, 2020, but canceled them after more than 20 of the congregation’s 1,500 members tested positive. The claim implies that the virus was spread through contact of the general church congregation. However, according to the news blog post written by the pastor of the church, Reverend Derek Allen, most of the initial positive tests were among the church staff members and volunteers, not the congregation. The first staff member was exposed to the virus outside of the church, who then spread the virus to his or her colleagues at a staff meeting. This led to “about half of the staff” and “some of [the] volunteers” testing positive. A more accurate claim of this spread would list a staff meeting rather than a church service as the setting for the initial spread. .
A California county official claimed that Calvary Chapel of San Antonio, after reopening in May 2020, experienced an outbreak of 50 people, despite practicing social distancing and adhering to other guidelines. This claim is false. Pastor Ron Arbaugh openly admitted to reporters that he allowed his congregation to “hug and shake hands,” which was in violation of the relevant guidelines. 
Some have cited a large COVID-19 outbreak that occurred in a South Korean church in February 2020 as a reason to limit the religious liberties of Americans. Several thousand members of the community, called the Shincheonji Church of Jesus, contracted COVID-19, confirmed by testing. The Shincheonji Church of Jesus is not at all comparable to most faith communities in the United States. The Korean church has been characterized by many as a “doomsday cult” and is notorious for its “unconventional evangelistic activities.” A group member was interviewed and stated that at services, congregants were so close together that they literally rubbed against each other. Additionally, they chanted and praised “at the top of their voice” for thirty minutes, then would listen to a sermon for a full hour. An anti-cult campaigner was interviewed regarding the surge of COVID-19 linked to this church, and he was skeptical regarding the integrity of the church based on its history of infiltrating other churches to recruit members to join the “cult”. The extent of the spread may very well have been compounded by the suspected deceitfulness of the leaders of the controversial cult. 
Others point to a February 2020 outbreak in Malaysia, where hundreds of cases were linked to a Muslim missionary group, called Tabligh Jamaat. This Islamic missionary movement, based in Southeast Asia, organizes mass gatherings to spread the Islamic faith. The outbreak in late February preceded any social distancing guidelines and orders in Malaysia, as it occurred more than two weeks prior to the restrictions instituted by Prime Minister Muhyiddin Yassin. Once again, this is an “apples to oranges” comparison. This example occurred in another country, involved different religious practices, involved missionary activities (with individuals approaching and engaging other individuals) and occurred early in the pandemic before any official guidelines were issued and when the Rt was likely still very high. 
Centers for Disease Control (CDC) released interim guidelines in May advising faith communities on how to best hold services while minimizing the risk of spreading COVID-19. It is important to note that the statement includes, “This guidance is not intended to infringe on rights protected by the First Amendment to the U.S. Constitution or any other federal law, including the Religious Freedom Restoration Act of 1993 (RFRA).” 
We should take those words to heart and remind our state and local officials that the First Amendment protects the exercise of religious beliefs. It is important for us not to accept the false narrative offered by the mainstream media and government officials regarding the risks of religious worship in congregations. Prudent, safe civil disobedience by religious congregations as well as aggressive legal action may be what it takes to ensure that the right to worship in congregations is never deemed nonessential again.
- Transcript of COVID Webinar Series interview of Robert Redfield, MD. https://www.buckinstitute.org/covid-webinar-series-transcript-robert-redfield-md/ accessed 5 August 2020.
- https://rt.live/accessed 29 August 2020
- CDC report of Washington State super-spreading event. https://www.cdc.gov/mmwr/volumes/69/wr/mm6919e6.htm accessed 6 August 2020
- A Conversation: What Do Science and Data Say About the Near Term Future of Singing May 5, 2020 Webinar https://www.nats.org/cgi/page.cgi/_article.html/Featured_Stories_/NATS_COVID_Resources_Page accessed 6 August 2020
- Naunheim, J Voice. 2020 Jul 2
- Risk Assessment of a Coronavirus Infection in the Field of Music (English translation) https://www.mh-freiburg.de/fileadmin/Downloads/Allgemeines/RisikoabschaetzungCoronaMusikSpahnRichter17.7.2020Englisch.pdf accessed 6 August 2020
- Konger, et al. Churches Were Eager to Reopen. Now They Are Confronting Coronavirus Cas New Work Times. Updated 10 July 2020. https://www.nytimes.com/2020/07/08/us/coronavirus-churches-outbreaks.html?_ga=2.32880442.567445811.1598230899-365553348.1597530794. Accessed 23 August 2020.
- https://www.statista.com/statistics/1103185/cumulative-coronavirus-covid19-cases-number-us-by-day/. Accessed 23 August 2020.
- https://www.statista.com/statistics/245491/church-attendance-of-americans/ . Accessed 23 August 2020.
- https://www.actionnewsnow.com/content/news/Butte-County-Public-Health-suspects-more-cases-to-come-from-Palermo-gathering-570968721.html. Accessed 23 August 2020.
- https://www.cdc.gov/mmwr/volumes/69/wr/mm6920e2.htm . Accessed 23 August 2020.
- https://stateofchildhoodobesity.org/adult-obesity/. Accessed 23 August 2020.
- https://www.cdc.gov/statesystem/cigaretteuseadult.html. Accessed 23 August 2020.
- https://www.cdc.gov/statesystem/cigaretteuseadult.html. Accessed 23 August 2020.
- https://www.jderekallen.com/post/five-lessons-i-learned-from-a-covid-19-spike-at-our-church .Accessed 24 Aug 2020.
- https://www.kens5.com/article/news/health/coronavirus/more-than-50-members-of-san-antonio-area-church-test-positive-for-the-coronavirus/273-9b756984-5761-4411-92db-398f94fa1cbf .Accessed 24 August 2020.
- https://www.scmp.com/week-asia/health-environment/article/3051629/coronavirus-super-spreader-south-korean-church-cult Accessed 24 August 2020.
- https://www.ncom/india-news/coronavirus-islamic-sect-chief-6-others-charged-for-delhi-nizamuddin-event-amid-covid-19-2204136. Accessed 24 August 2020.
- Considerations for Communities of Faith, CDC, 23 May 2020. https://www.cdc.gov/coronavirus/2019-ncov/community/faith-based.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fphp%2Ffaith-based.html . Accessed 7 August 2020.
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