High risks for
Some important coronavirus-related aspects of risk assessment within professional dance ensembles
Boglárka Simon-Hatala schreibt in ihrem Artikel über die besonderen Risiken, denen der professionelle Tanz in der aktuellen Covid-19-Krise ausgesetzt ist. Es gibt hier erst wenige faktenbasierte Studien, erste Vorschläge von Versicherungen oder professionellen Organisationen zum Umgang mit dem Virus sind nicht einheitlich. Die Autorin listet dezidiert Gründe für das hohe Risiko auf, das Profi-Tänzer eingehen, zum Beispiel die körperliche Nähe, die der Tanz erfordert oder auch die Tatsache, dass der Tanz unweigerlich Körperflüssigkeiten (Schweiß, Tränen, Blut…) mit sich bringt. Die Bundesländer und einzelne Theater in Deutschland haben unterschiedliche Präventionsmaßnahmen ergriffen. Auf jeden Fall kommt dem Bereich Ballett in den Häusern hier eine besondere Beachtung zu: Die Frage, wer wie Erste Hilfe im Fall von Verletzungen im Training oder auf der Bühne leistet, ist nicht beantwortet. Das Tragen von Masken bringt im Bereich Tanz einerseits keine wirkliche Risiko-Minimierung, andererseits behindert es das eigentliche Tun der Tänzer. Wenn Ballettklassen oder Proben von den Arbeitgebern zur Pflicht gemacht werden, so fordert die Autorin, dann müsse das erhöhte Risiko finanzielle kompensiert werden.
Der eigentliche „job“ des Tänzers/ der Tänzerin ist die Aufführung. In der häuslichen Isolation können Tänzer/-innen Fitness und Muskelstärke aufrecht erhalten, aber die erforderliche Bühnenpräsenz kann hier nicht geübt werden. Deshalb fordert die Autorin für den Bereich des Tanzes eine Phase des Übergangs, der „künstlerischen Wiedereingliederung“, wenn die Theater wieder spielen dürfen. Schließlich weist sie auch auf die mentalen Folgen hin, die die Pandemie für Tänzer mit sich bringt. „Ich plädiere für eine organisierte und zentrale Intervention: Wir brauchen finanzielle Ressourcen, professionelle Anleitung und Experten, um die langfristigen Konsequenzen zu reduzieren.“
The recent pandemic of Covid19 is a great challenge for our societies. We had to implement new social and behavioural norms and we reorganised many aspects of everyday life, work habits and work environments. Some sectors were under detailed investigation to identify Covid19 associated risk factors (in health care or aviation for example), but in case of most artistic activities and jobs we must rely on common sense, assumptions and guessing due to the lack of evidence based studies. This is the case in professional dance, too. Dance medicine communities and organisations are actively debating what measures and methods could be widely proposed for professional dance, but it is an ongoing process. Some insurance companies like Unfallkasse Hamburg1 and professional organisations like Tanzmedizin Deutschland2 already made suggestions, but their guidelines are not entirely identical.
What we know is that professional dance is associated with the increased presence of certain factors commonly accepted to contribute to the spread of viruses, contamination and risk of infection. Given the small amount of time since the beginning of the recent pandemic, scientific resources are limited, but according to the research of Jang et al. 20203, dance classes are representing a high risk for coronavirus clusters, and the authors suggest minimizing vigorous exercise in confined spaces during outbreaks. We can assume that professional dancers belong to an extremely high-risk group for coronavirus transmission.
If we perform risk assessment in professional dance companies, we can identify, among others, the following risk factors associated to virus transmission:
Technically and artistically, professional dance is very much bound to close physical contact of human beings: couples or groups. Physical distancing can only be applied to very limited activities, but not to the entire profession in all its complexity.
Professional dance is typically an indoor activity and air-conditioning in dance studios rarely involves disinfectant features.
Dance floors must be cleaned with specific products to avoid dangerous friction or slipperiness, and not all these products have virucidal properties.
Professional dance is typically a hard physical activity challenging the respiratory functions: fast and heavy breathing is usually inevitable4.
Professional dance is associated with excessive spread of various bodily fluids (blood due to skin damage, saliva, sweat, tears) and other organic matter like skin particles spreading on the floor, in the air, on the equipment of the work environment as well as on dance clothes and shoes.
Some dance equipment, training tools, dance shoes and especially costumes are extremely hard or even impossible to disinfect.
Costumes and wigs are typically not dedicated one dancer only, props change hands permanently.
Make-up and hair departments of theatres lack disinfecting routines with regard to viruses and the technology excludes most of the possible methods of physical distancing.
The social habits of the community involve much physical contact: hugs, touches etc.
These properties of professional dance raise the concern that the profession must be considered of elevated risk for work-related health problems in an epidemiological context and should be financially and legally treated as such for the full duration of the Covid19 pandemic.
Different theatres in different federal states of Germany apply slightly different prevention measures in response of the recent pandemic, but all institutions, in theory, require physical distancing and suggest or make it mandatory for employees to wear facial masks of some kind. They require dancers to participate in daily ballet classes and in some cases in rehearsals.
Considering professional dance, these policies raise concern from the point of view of prevention and health management.
First, professional dance comes with a considerable risk for acute
injuries, and there are no proper protocols and education programs addressing first aid if physical distancing is a requirement and clarifying, who is responsible for it. In association with in-house health management, it is unclear, how physiotherapy and massage service should function safely in theatres – if there is a way at all.
Secondly, surgical masks, hygiene masks and simple textile masks are not designed for intense physical training. There is no reliable scientific research about every mask type’s influence on the oxygenation, but we do know that N95 masks, which are recommended for having proper virus filtration, have a significant impact on heart rate, oxygenation and thermophysiological responses5. There is feedback from dancers around the world about headache, unusual hyperventilation and quickly appearing heavy breathing while taking ballet class in mask. These are anecdotal but still relevant concerns as they suggest the risk of hypoxia and/or hypercapnia (CO2 retention). We assume that the problem is not only linked to the resistance while inhaling, but that the CO2 of the exhaled air cannot properly be replaced by fresh, oxygenated air as it stays behind the mask. It is highly questionable if wearing a mask during dance training is safe or under which circumstances is it safe and under which it is not. In respiratory therapy and in athletic training we use resistance to improve condition, but these special masks are expensive and not recommended for infection prevention – however some of them might be valid competitors to simple hygiene masks.6
Thirdly, the mask potentially has an impact on coordination, alignment and movement patterns, it can distract the attention and restrict the focus, and this might influence the risk of injury.7 If wearing a mask is a necessity from an epidemiological point of view, but cannot be guaranteed to be safe equipment for ballet training, then, perhaps, safe ballet training is not possible at all in times of an epidemic? Perhaps these circumstances must also be considered extra high work-related health risks and should be financially compensated as such with a bonus, if the class or rehearsal is mandatory and a mask is required. In my opinion, the institu-tions, unions, dance medicine organisations and authorities should run a dance-specific risk assessment to clarify these aspects and properly address them.
It is unclear when performances in front of an audience will be possible again, some experts expect a second wave of the virus.8 The job of a performing artist is to perform on stage, and all other activities within working hours, including ballet class and rehearsals, are supposed to facilitate performing, but they are not the job itself. To enable professional dancers to practice their dancing skills and provide them with the space and professional ballet masters to stay in shape is perhaps the obligation of their employer due to Fürsorgepflicht, but can it be mandatory, if it is uncertain, when performance, which constitutes the actual job, will be possible again? These aspects, too, are to be discussed by the theatre community.
Home isolation renders proper maintenance of dancing skills virtually impossible. With carefully designed training programs it is certainly possible to keep up muscle strength, fitness and stamina, but dance is about the expressivity of the movement, about a level of complex coordination and stage presence that no other type of movement can provide and that cannot be fully preserved without real stage performances. These skills require a transition period to rebuild once the lockdown is over, and this transition is optimally prepared by a network of interdisciplinary experts. Adaptation does not happen automatically. The transition can be regarded as an artistic rehabilitation – this time for an entire profession. Without this guided transition we must expect higher risk of injury and less efficient coping strategies. Strategic guidelines and programs cannot be replaced by simply opening the studios.
We are expecting a mental health crisis as a consequence of the coronavirus disease, but performing artists can be extremely affected, and the dance industry is perhaps the sector most at risk. For many artists the lack of performance opportunities means a lack of self-expression and a lack of communication: beyond isolation, it amounts to being silenced. The career of dancers is very short and for them the recent situation might result in a half year without performance until the next season. Financial security is evaporating for many freelancers, foreign dancers are restricted to visit their families in their home country, high end dancing skills are dropping: this is an extreme situation from the point of view of mental health, it is unprecedented and hitting an entire artistic sector. Several studies suggested in the past, that performing art is associated with higher incidence of mental health problems9 10 11under normal circumstances, too. I would like to call for an organised and centralised intervention: we need financial resources, professional guidelines and experts to reduce the long-term consequences.
3 Jang S, Han SH, Rhee J-Y. Coronavirus disease cluster associated with fitness dance classes, South Korea. Emerg Infect Dis. 2020 Aug [date cited]. https://doi.org/10.3201/eid2608.200633
4 Cohen, J. L., Segal, K. R., Witriol, I., & McArdle, W. D. (1982). Cardiorespiratory responses to ballet exercise and the VO2max of elite ballet dancers. Medicine and science in sports and exercise, 14(3), 212-217.
5 Li, Y., Tokura, H., Guo, Y. P., Wong, A. S., Wong, T., Chung, J., & Newton, E. (2005). Effects of wearing N95 and surgical facemasks on heart rate, thermal stress and subjective sensations. International archives of occupational and environmental health, 78(6), 501–509. https://doi.org/10.1007/s00420-004-0584-4
6 Porcari, J. P., Probst, L., Forrester, K., Doberstein, S., Foster, C., Cress, M. L., & Schmidt, K. (2016). Effect of wearing the elevation training mask on aerobic capacity, lung function, and hematological variables. Journal of sports science & medicine, 15(2), 379.
7 Hinkamp, D., Morton, J., Krasnow, D. H., Wilmerding, M. V., Dawson, W. J., Stewart, M. G., ... & McCann, M. (2017). Occupational health and the performing arts. Journal of occupational and environmental medicine, 59(9), 843-858.
8 Kissler, S., M. et al., Projecting the transmission dynamics of SARS-CoV-2 through the postpandemic period (2020). Science 14 Apr 2020 DOI/org/10.1126/science.abb5793
9 Nordin-Bates, S. M. (2012). Performance psychology in the performing arts. The Oxford handbook of sport and performance psychology, 81-114.
10 Ostwald, P. F., Baron, B. C., Byl, N. M., & Wilson, F. R. (1994). Performing arts medicine. Western journal of medicine, 160(1), 48.
11 MacCabe, J. H., Sariaslan, A., Almqvist, C., Lichtenstein, P., Larsson, H., & Kyaga, S. (2018). Artistic creativity and risk for schizophrenia, bipolar disorder and unipolar depression: a Swedish population-based case-control study and sib-pair analysis. The British Journal of Psychiatry, 212(6), 370-376.
Boglárka Simon-Hatala ist eine international anerkannte Physiotherapeutin (Ausbildung an der Medizinischen Universität Budapest) und Expertin für Antidiskriminierung am Theater, Gesundheitsberaterin und Publizistin. Als Therapeutin hat sie sich auf Prävention und Rehabilitation für Klassische Balletttänzer spezialisiert.