Editor’s Note: An earlier version of this article implied that people should not sing during gatherings. The author’s suggestion is to wear a face mask when singing or talking. (See updated table for more information.)
Over the past four months, the spread of a new coronavirus has exploded across the globe, leaving packed ERs, ICU patients on ventilators, and families grieving over the loss of their loved ones. To limit the spread of this virus, most governments implemented strict stay-at-home orders. This very blunt instrument was necessary because many countries were simply unprepared for the rapid spread of this virus. If nothing was done, the rising number of infections would have overwhelmed health care systems, and deaths would have quickly escalated.
During this period, churches across the US and around the world have closed their doors to in-person worship and ministries. As with many preventive actions, we may never know how this has limited the spread of COVID-19. But as a global health professional who has worked for 25 years to control diseases around the world, I am certain that this has prevented many infections and deaths that would have occurred among congregants and their families and friends.
After six or more weeks of stay-at-home orders in the US, unemployment claims are piling up, people are getting antsy in their homes, and loud voices are increasingly calling for governments to relax their restrictions.
Public health experts warn that the US lacks the testing, contact tracing, and quarantining capabilities needed to bring and keep the pandemic under control, yet some states are already loosening their restrictions and allowing “nonessential” businesses to reopen.
I propose that the way forward is to take a step-by-step approach that helps the global church live out its missional calling, meet the needs of its congregants, and protect the health of those in the church and in the community.
The Great Commandment states, “You shall love the Lord your God … and love your neighbor as yourself” (Matt. 22:37–39, ESV). During this pandemic, love for ourselves is expressed in the ways we protect ourselves from getting infected. In the same way, love for our neighbor is expressed in the ways we protect them from getting infected.
Even as we focus on preventing COVID-19 infections, however, we should not neglect spiritual, emotional, and social needs—in ourselves and others. During this period of social distancing, it is perhaps even more important that churches meet these needs.
As Christ’s disciples, these needs are met as we live out our calling to worship, pray, encourage, witness, disciple, and serve. However, we now must do these in a way that minimizes the risk of COVID-19 transmission. Therefore, we need to use scientific knowledge about this virus to prevent its spread in our churches.
With the best minds in the world working on COVID-19 right now, there is a rapidly expanding body of scientific knowledge about this virus. We are also accumulating lessons from many countries on what is and is not working to control the spread of COVID-19. Some of these recent insights are particularly relevant to churches as they consider how to resume in-person ministries:
Contrary to our initial assumptions, we now know that COVID-19 can be transmitted before a person develops symptoms. This explains why the virus spreads so easily and stealthily, and it greatly complicates efforts to contain its spread.
We also know that not every infected person will infect another person. Other factors are needed to facilitate transmission. They include:
・Infectiousness of a COVID-19 patient
・Actions that increase the release of respiratory droplets and aerosols into the surrounding air
・Proximity to an infected person (within six feet is considered high risk)
・Enclosed environment with limited ventilation to the outside
・Amount of time spent with an infected person
・Type of social network, e.g. inter-generational mixing
There is growing evidence that younger people and children are less susceptible to COVID-19. Children are also less likely to display symptoms when infected with the coronavirus. However, the quantity of viruses they harbor and their ability to spread to others may not be different. Because older people are more susceptible to getting COVID-19, the implication is that intergenerational contact should be minimized to reduce COVID-19 transmission.
Initially, most of the attention about the danger of COVID-19 focused on the elderly because they have a much higher case-fatality rate. Then we learned that younger adults with common chronic conditions like hypertension and diabetes also have an increased risk of serious complications. In fact, nearly 60 percent of COVID-19 hospital admissions in the US are for those less than 65 years old.
A recent study reported that 45 percent of American adults have factors that place them at risk for serious COVID-19 complications. Because those attending churches are on average older than the general population, an even higher proportion of church congregants are at risk for serious COVID-19 complications.
Testing, contact tracing, and quarantining of cases and contacts can mitigate the COVID-19 epidemic without a major lockdown. However, such actions must be taken very rapidly and effectively. South Korea and Taiwan have done this successfully. Within two or three days from symptom onset, COVID-19 patients are tested and most of their contacts are effectively quarantined. This has worked because South Korea and Taiwan have some of the highest testing rates in the world and a well-trained cadre of contact tracers to quickly locate contacts and implement quarantine. They also use some electronic tracking, which may not be acceptable in other countries.
There is good evidence that using a face mask substantially reduces the release of respiratory droplets and aerosols into the surrounding air, even when a person coughs or shouts. The primary benefit from using a face mask is to reduce the spread of COVID-19 from the source of infection—an infected person. Homemade masks are less effective than surgical masks but still helpful. In addition, wearing a face mask prevents an infected person from rubbing her nose and then depositing viruses on surfaces that she touches. Face mask users also get limited protection from COVID-19 infection.
Several states have started to lift stay-at-home orders, even though their COVID-19 case counts remain high or have just started to decline. This will lead to an increase in transmission and new cases. This increase can be mitigated by extensive testing, effective contact tracing, and quarantining of contacts. But no state yet has the testing capacity and the trained personnel to carry out effective tracing and quarantining.
Then there is the challenge of COVID-19 spreading from one state to another. As long as one part of the country has a poorly controlled epidemic, states that have significantly reduced their cases will remain vulnerable to COVID-19 spread from those areas. The same can be said of spread from one country to another. A prime example of this is Singapore, which controlled the first wave of infection from China only to experience a second wave of infection from Europe.
The church is a high-risk setting for COVID-19 transmission. Church activities contain multiple factors that facilitate airborne COVID-19 spread (see table below). In addition, our congregants are at greater risk for serious complications from COVID-19. Therefore, churches should carefully consider when and how to resume in-person ministries and have a clear plan to do so. This plan should achieve the following:
・Mitigate the risk of airborne COVID-19 transmission during church activities.
・Be able to dial up and dial down church activities as COVID-19 infection in the community waxes and wanes.
・Be able to rapidly identify contacts with an infected person and help trace them if necessary.
・Resume in-person church activities only when there is clear evidence of a declining and low level of infection in the community.