In the UK government’s June 23rd guidance which permitted the reopening of pubs, there was a bitter and unexpected blow to musicians: all live performance remained banned indefinitely. The ruling seemed cruelly unfair: how could it have been OK for pubs to reopen with people in close proximity talking in loud voices, when playing a musical instrument or singing at a distance of many metres from the audience was still banned?

Declan Costello
Declan Costello

The arts world desperately needed some science to back up its case and a group of choral directors found the ideal person to turn to: Declan Costello, an Ear, Nose and Throat consultant whose speciality is the treatment of singers – he styles himself “The Voice Doctor” – and who is himself an accomplished professional tenor.  (When Costello isn’t engaged in his usual dizzying round of clinics, operations and editing of scientific journals, he particularly loves singing Bach and Renaissance music, touring with groups like Polyphony). Costello came up with a proposal for a rigorous scientific study that would establish the necessary facts: he and colleague Natalie Watson found the right contacts in the UK government to get the study approved and funded – a process that happened remarkably quickly. “The proposal had to be approved by Public Health England because it’s a medical trial using human participants and had to go through the usual medical trial ethics procedures, and that went through in literally 24 hours, which is completely unheard of in medical trials. We got funding from DCMS [the UK Department for Culture, Media and Sport] within a couple of weeks as well, which again is just totally unheard of.”

Single Singer

It’s all about droplets: COVID-19 mostly spreads through virus particles in the droplets of vapour emitted when people breathe, speak, sing and/or cough or sneeze. Larger droplets, of diameter between 5 and 10 µm, fall to the ground a metre or so in front of you (which is what drives social distancing rules). But some circumstances, including the playing of wind instruments, can cause the formation of “aerosols” or “microdroplets” (with diameter below 5 µm): these can hang in the air for a great deal longer, especially indoors in unventilated spaces.

“The purpose of the study,” Costello explains, “is to look at the amount of aerosol and droplets generated in a variety of different vocal activities, including speaking, breathing, shouting, singing and playing wind and brass instruments. The idea is to compare all of those things with each other and to work out whether more aerosol droplets are produced in singing and when playing brass than in, for example, shouting”. Clearly, if singing produces no more aerosol than shouting, then it’s unreasonable to ban singing while reopening pubs.

Flute

It’s vital – and difficult – to ensure that you’re really measuring what you think you are. The quantities of aerosol produced by singing and brass playing are small compared to the considerable amount of background particulate matter in environments like a rehearsal studio. “We’re doing the study in an extremely clean air environment. We chose an operating theatre with a special purification system called ‘laminar flow’, which means that there is literally zero background particulate matter, so we can be absolutely certain that anything picked up by the devices is definitely coming from the person playing or singing.” Public Health England have been accused of “nationalism” for ignoring research done in other countries such as Austria and Denmark, but that’s unfair, says Costello: “SAGE and PHE are looking at all of the research and evaluating it very carefully. It’s a vastly experienced bunch of scientists in those groups and I think it's fair to say that all of the studies that have come through so far have had very substantial holes in them. I’m not aware of any other studies that have been done in such a clean and sterile environment.”

Two private clinics in London, the Schoen and Fortius Clinics, have made available sterile operating theatres. There, at evenings and weekends for the last fortnight, the study team have taken measurements from a variety of singers and instrumentalists using many different measuring devices. Now, it’s over to a team from Bristol University to “crunch a huge quantity of numbers over the next few weeks to turn them into some sort of meaningful results”. Costello is keenly aware of the pressure to make a decision from thousands of people reliant on music for their careers, so the hope is for a fast track set of preliminary results to be made available to PHE and others around middle to late August, with a fuller, more rigorous paper to be submitted to scientific journals at a later date.

French horn

It’s worth emphasising that this research only forms one piece in a relatively complex jigsaw. Measuring the quantity of droplets and aerosol is all very well, but it doesn’t tell you how much infective material is actually contained in the droplets. There are aerobiologists who study this, says Costello (it’s a specialist field and he’s not one of them), but their job is made difficult by the small number of people currently infected and the ethics of working with infected patients. Secondly, even if we had a good handle on the amount of virus found in droplets of various sizes, we still have no idea how much virus has to be ingested to cause infection. There’s a lot of research across the world that needs to be completed before the full picture becomes clearer.

Other questions remain. Commendably efficient as the DCMS has been in approving and funding this study, how did we reach June without them having done something proactively, rather than waiting for someone to bring the idea to them? And why are the press offices of both PHE and the DCMS being so secretive, both refusing to give out any details of the obviously useful research they’re conducting?

But for now, what we need most is clarity. On July 11th, the DCMS issued new guidance stating that “singing and the playing of brass and wind instruments will be permitted in a managed and controlled professional working environment to minimise risk”. The advice is long, tangled and contingent on risk assessment by the arts organisations involved, who are told what to consider but given little help in how to make the assessment. This study by Costello and the Bristol team will certainly represent a huge step in enabling sensible decisions to be made. The results can’t come soon enough.