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Protests may add COVID-19 cases and compound racial disparities

Protesters face higher risk of getting ill from virus if tear gas deployed

Demonstrators gather to protest the death of George Floyd near the White House in Washington on Sunday.
Demonstrators gather to protest the death of George Floyd near the White House in Washington on Sunday. (Caroline Brehman/CQ Roll Call)

Recent protests against police brutality could exacerbate the COVID-19 pandemic, especially among African Americans, who already have suffered disproportionately from the coronavirus that causes the disease.

The concerns come as medical societies like the American Medical Association and Association of American Medical Colleges call for acknowledging racism and violent policing as public health crises.

The protests are both increasing the risk of COVID-19 transmission and forcing a conversation about inequality in health care caused by social factors, experts said. 

Health officials say protesting during a pandemic makes social distancing difficult. Though transmission is less likely when protesters are outdoors and wearing masks, chanting and yelling may increase the number of infectious droplets and aerosols. Tear gas causes protesters to cough and remove masks and could make COVID-19 more deadly.

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“There’s no doubt that everyone is concerned about people mingling. We’ve been hoping for a safe summer, that people would return back into the community in a manner that encouraged physical distancing, wearing a mask and washing hands,” said American Public Health Association Executive Director Georges Benjamin. “If you could plan an event to accelerate the risks of catching COVID-19, this would be it.” 

Benjamin also highlighted the health impact of the issues that brought protesters into the streets. 

“The fear of being able to drive down the street or walk down the street without losing your life causes enormous stress. Far too often, that’s an issue,” he said. “We know racism has driven a whole range of policies around things like segregation and housing discrimination and income discrimination that reduces one’s ability to live in a prosperous society.”

Josh Michaud, associate director for global health policy at the nonpartisan Henry J. Kaiser Family Foundation, said it’s important to analyze recent events in a wider context.

“We have to take into consideration why these protests are happening in the first place. Just a straightforward public health view of this is blinkered, and it’s not taking into consideration the broader aspects of why the protests are happening and why they may be necessary in reaction to events,” he said.

Michelle A. Williams, dean of faculty at the Harvard T.H. Chan School of Public Health, addressed this in a public letter.

“That reality is apparent not just in the police brutality that disproportionately claims the lives of Black Americans, but in the legacy of slavery and discrimination that persists in countless social determinants of health,” she wrote. “While the COVID-19 pandemic has newly laid these inequities bare for all Americans to see, the underlying injustices have endured for generations.” 

The country is witnessing one of the most widespread nationwide civil rights protests in history and it’s coming just as COVID-19 cases are flattening or even declining in some places, said American College of Emergency Physicians spokesperson Aisha Terry, a George Washington University School of Medicine and Milken Institute School of Public Health emergency medicine and health policy associate professor. “In the midst of this perfect storm with thousands of people protesting, there’s no doubt it could lead to a resurgence of COVID-19 cases.”

She stressed any protesters should “protest with a plan,” by wearing a mask and eye protection and disinfecting their hands often.  

City officials also expressed concerns that protests could increase the spread of the virus.

“If you were out protesting last night, you probably need to go get a COVID test this week,” Atlanta Mayor Keisha Lance Bottoms, said in a press conference Sunday. “There is still a pandemic in America that is killing black and brown people at higher numbers.”

The top health official in D.C. echoed these concerns.

“Outdoor mass gatherings present a concern because individuals do not properly social distance,” District of Columbia Department of Health Director LaQuandra Nesbitt said Monday. “We have shared over and over again that face coverings are not a replacement for an individual’s ability to not social distance.”

Other drivers of infections 

Some experts caution it’s too early to say whether these gatherings will have more of an effect than states lifting business restrictions or other situations.

Lax infection control at prisons, long-term care facilities and workplaces deemed “essential” such as meatpacking plants, as well as states that reopened before a recommended two-week decline in cases, have already compromised the gains of mitigating the virus’ spread.

“Will the protests lead to some additional infections? Quite possibly, but I’d be more concerned about prisons and jails, ICE detention facilities, meatpacking plants, [and] Amazon warehouses creating superspreading events as these involve indoor, repeated, long-term exposures,” said Yale School of Medicine epidemiologist Gregg Gonsalves.

“The new infections that may be generated by protests pale in comparison to the larger drivers of the epidemic in the U.S. and it is not right to suggest that the failure at the federal level, premature action by states and the protests present equivalent dangers, because it’s simply not true,” he said.

Terry said a “second wave” of cases wouldn’t have a single cause.

“There are so many factors to take into consideration in being able to accurately determine the cause of a resurgence of cases,” Terry said. “Generally the country has been reopening over the past few weeks, the weather has been warming over the past few weeks, so people are getting out of the house not adhering to social distancing to the extent they were before.” 

“Different states have experienced waves of the pandemic at different times, so waves of the infection could be a problem regardless of protests,” she continued.  

Higher risks from tear gas 

Reports of tear gas use by officers in response to nonviolent protests raised concerns about how it accelerates disease transmission, as it forces people to pull off their masks to breathe.

“If people are coughing or sneezing because they have had tear gas or pepper spray, that would be an additional risk,” said Leana Wen, an emergency physician and public health professor at George Washington University and former Baltimore health commissioner.

Tear gas that makes it hard to breathe also will likely make COVID-19 more severe, experts say. 

Tear gas hits the eyes, nose and mouth, and sometimes the lungs “where the virus likes to hang out,” said John Balmes, a pulmonary physician, professor of medicine at University of California, San Francisco and American Lung Association spokesperson.

Balmes said while there isn’t yet research on tear gas and COVID-19, it’s probable that it exacerbates the disease in the way that other irritants like air pollution and cigarette smoke do. 

“If the Secret Service at the White House had asked me for medical advice on crowd control and asked if they should use tear gas, I would have said, ‘I don’t think so,’” Balmes said.  

If an asymptomatic protester with an underlying breathing issue was exposed to tear gas, that would be a “triple whammy,” Balmes said. 

Heavy or repeated exposure to tear gas can injure the respiratory tract and create long-term problems like chronic bronchitis, potentially leading to increased susceptibility to COVID-19 later, though those cases would likely be rare, said Howard M. Kipen, a Rutgers Environmental and Occupational Health Sciences Institute expert.

Kipen said although tear gas has been around for a long time, “there’s not a lot of reliable information” on its long-term effects.

“It’s better off to not have anybody’s lungs exposed to tear gas,” he said.

Vulnerabilities exacerbated

Black Americans already face a disproportionate number of infections and deaths from the virus, and experts worry the health impact of the protests might be most severe for the nation’s most vulnerable.

“Black Americans are nearly three times more likely to die from COVID-19 than white Americans. It’s the same communities that have higher numbers of essential workers, that have less ability to social distance, that have a higher degree of underlying health conditions that are already hardest hit by COVID,” Wen said.

Wen, who was commissioner during the unrest after the death of Freddie Gray, said arson and property damage can have other public health consequences.

In Baltimore, she said almost a dozen pharmacies were burned down or otherwise forced to close, which limited access to medicine and food for many people.

Daniel J. Schober, DePaul University assistant professor of public health, said Chicago city officials recommended protesters who did not wear protective equipment such as masks to self-isolate for two weeks.

“If you look at communities of color in Chicago, that’s unlikely to happen because they live with a lot of people and live in very close quarters and they also have jobs where they don’t have the luxury to work from home,” he said.

Schober said while he feels treatments for COVID-19 will eventually be available, societal changes to improve the lives of minorities might not be made.

“My biggest concern is that we’re not going to as a society take the opportunity to think deeply about big structural changes to things like the health system and the employment system,” he said. “As a society, we need to be thinking about some of the structural changes that have to happen for less disparities and to protect ourselves against another pandemic.”

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