How can physicians advise faith communities during the COVID-19 pandemic?

Dear Editor,

We are a group of physicians at the Mayo Clinic with distinct and different religious backgrounds. Our faith communities asked us for advice about how to follow government regulations during the current pandemic while still living out our beliefs. They wanted to balance health risks with the values of collective meetings and interpersonal service. This letter highlights how we gave advice to faith-based groups from Jewish, Muslim, and Christian backgrounds (see Table 1 ). We hope that as the current pandemic evolves, these experiences may be useful to healthcare and public health professionals who have similar opportunities to interact with faith-based groups.

Table 1.

Facing COVID-19: Experience of three faith communities in Rochester, Minnesota, USA.

	Jewish Synagogue	Muslim Mosque	Christian Church
Situation	Two Jewish congregations (a Reform temple and a Chabad House) serve approximately 1000 area residents and visitors.	Four mosques serve a few thousand Muslims. Twice annual Islamic holiday congregational prayers (Eid ul-Fitr and Eid ul-Adha) regularly draw 2500–3000 Rochester area congregants.	91 distinct Christian congregations with weekly attendance of 9000 evangelical Protestants, 8000 Roman Catholics, 7000 Lutherans, and 2000 mainline Protestants.
Advice Process	The Chabad House, synagogue rabbis and lay governing board sought advice from health care professionals and scientists in their congregations. CDC, state governor, health department and religious guidance from national Jewish organizations informed their decision to suspend in-person activities, adhere to social distancing guidelines and promote community health, safety, and spiritual wellbeing.	Lay leaders, imams of area mosques and Muslim health professional organizations reviewed public health guidance and recommendations in addition to religious principles. Health professionals provide ongoing advice on reopening congregational activities in accordance with public health and governmental directives.	A task force of health professionals within the largest evangelical congregation of 6000 was formed to review relevant data and provide recommendations to church staff. Continued guidance is being provided to the church on adaptations and reopening ministries as data and health department and governmental guidance is modified.
Relevant Teachings and Principles	“Pikuach nefesh” - saving a life, means that preservation of human life overrides virtually any other religious rule, with few exceptions. “You shall therefore keep my statutes and my rules; if a person does them, he shall live by them: I am the LORD.” (Leviticus 18:5) Jews should respect and obey authorities unless laws are contrary to the laws of the Torah. Heeding local governments' guidance to saves lives has been a guiding principle behind Jewish organizations' active support for the state-wide response: “Dina demalchuta dina” - “the law of the land is the law” (Bava Kamma 113a, The Talmud).	The guiding principles of Islamic sacred law (shari'ah) are preservation of religion, life, intellect, lineage, honor, and wealth. Regarding preservation of life: “… if anyone saved a life, it would be as if they saved the life of all mankind.” (Surah al-Ma'idah 5:32) Prayer (salah) is a pillar of Islamic practice. Congregational Friday prayer (salah al-jumu'a) at the mosque is an important socio-cultural activity and is obligatory for men, though both men and women attend. Muslims are commanded to respect and obey the governmental authority, unless contrary to God's laws. “O you who believe! Fulfill [your] obligations” (Surah al-Ma'idah 5:1)	Principle of ‘Love your neighbor as yourself.’ (Matthew 22:39) guides Christians to love by putting the needs of others above their own. Gatherings are important for spiritual growth and worship. “… spur one another on toward love and good deeds, not giving up meeting together …” (Hebrews 10:24–25) Christians should respect and obey government authorities unless laws run contrary to God's laws. “Let everyone be subject to the governing authorities, for there is no authority except that which God has established … For the one in authority is God's servant for your good.” (Romans 13:1, 4)
Challenges	In Orthodox and Conservative Judaism, use of electricity, driving, and other forms of work are prohibited on the Sabbath and holidays. As a result, Sabbath and holiday (including Passover) services at the Chabad House could not be digitized. Passover is a major holiday centered around family gatherings (Seders) and congregational activities. Many people travel to be with family. Traditional community Seders were unable to be held. Burial and mourning (shiva) rituals are communal, and new processes had to be created to accommodate social distancing rules.	Friday prayer (salah al-jumu'a) cannot be fulfilled through remote broadcast, leading to a loss of a very important aspect of faith expression and practice. During the month of Ramadan, adherents traditionally gather at mosques after breaking the daily fast (iftar) to observe nightly supererogatory congregational prayers (taraweeh). These activities were suspended. Allowable adaptations to customary Muslim funerary practices (e.g., ritual washing of the deceased, prayers, and funerary procession to burial) were enacted to mitigate risks.	A few Christian leaders nationally challenged the governmental authority to cease church meetings. Easter is a key holiday for Christians, celebrating Christ's atoning sacrifice and resurrection. Communal celebration of Easter occurred online. Congregants partook of self-provided (non-consecrated) communion elements together virtually on Good Friday. A new, though younger and tech-savvy, senior pastor started the week the stay-at-home order was issued. Leadership transitions and team dynamics were in flux.
Solutions	Chabad House transitioned to weekly pre-Shabbat virtual gatherings and the reform synagogue transitioned to virtual Shabbat worship services. Chabad House delivered “Seder-to-go kits” and hosted a virtual Seder training seminar. Passover Pre-Seder and Seder were done using online audiovisual technology. Rabbis were available for virtual chaplaincy at hospital and virtual presence at funerals and shiva (bereavement) services. Both groups organized shopping for the elderly and high-risk, including purchases of kosher-for-Passover food. Teens and young adults from the synagogue set up virtual connectivity for the elderly. Members of the congregation made masks for each other and the community.	Mosques suspended congregational activities (this was supported by a prior fatwa) [5]. Many mosques used virtual meetings to link imams and leaders with congregants through lectures and to meet the spiritual and mental health needs of the community. Friday special lectures by mosque imams were also made available online. Mosques and Muslim organizations began using virtual means to address the social welfare of this uniquely heterogeneous community. During Ramadan, mosques and Muslim organizations locally and nationwide increasingly published online programs to provide spiritual guidance and education. Several service projects were organized including mask sewing, food collection and distribution, and elder support.	The Task Force advised that church should continue to meet together virtually and encourage each other in loving and caring for others. Church leaders were encouraged to find unique opportunities to develop and maintain ministry despite distancing. All services/ministries transitioned to virtual meetings including livestream worship services with singing led by a small number of well-distanced vocalists, none behind another. Prayer meetings, daily devotionals, youth and Bible study group meetings were held online (using virtual audiovisual technology). Service projects were organized (sewing masks, delivering food, blood donation). Telephone and online audiovisual outreach arranged for the elderly and infirm.

Rochester, Minnesota, a diverse Midwestern city of approximately 110,000, has a strong healthcare ethos as the home of Mayo Clinic serving nearly 1 million unique patients each year. Rochester is home to several immigrant populations and a variety of faith communities including two Jewish synagogues, four Muslim mosques, and 91 Christian churches. Approximately 30% of the population is estimated to participate in a faith-based gathering each week. As COVID-19 spread across the world, large gatherings emerged as a central risk factor for virus transmission. Some outbreaks were tied to meetings of religious groups [1,2]. Our faith leaders asked us as clinicians within their communities for integrated medical advice on how to approach this present plague. We formed formal or ad hoc task forces with other medical colleagues to answer the following questions.

First, who should avoid worship meetings? Early in the pandemic, it became clear that older adults and individuals with complicated medical conditions were most at risk of severe disease. Physicians informed faith group leaders of the specific risk populations and of means to reduce transmission [3], but that all indoor gatherings risked becoming super-spreader events. Selective suspension of gatherings for the high-risk was initially considered, though these mostly older members expressed the greatest sense of obligation to meet for worship. Physicians advised distancing of congregants (“no hugs, no handshakes”) and use of sanitizer during meetings. Clinicians were able to clarify medical risks by discussing means of transmission (including aerosolization while singing) and the effectiveness of preventive interventions (masking, distancing between individuals).

Second, what scientific facts should guide decisions to comply with government instructions to cease gathering for worship? As community spread of SARS-CoV-2 was established, faith leaders’ requests for input shifted from reducing risk during meetings to the cancellation of group gatherings. Leaders of faith communities are responsible for sorting and synthesizing information, and they wanted physician experts from within their communities on whom they could depend, particularly when governmental statements differed from the perceived facts and when restriction of gatherings touched on core tenets of faith. Clinicians provided faith leaders with: 1) explanations of scientific knowledge (with frequent updates as new information became available), 2) recommendations made by various groups of medical and scientific experts, and, 3) guidance on ways to address common myths and misinformation.

Physicians advising faith communities saw the value of clear communication. Faith leaders appreciated ready access to trusted congregants who could decode scientific reports, decipher news communications, and determine what information was relevant. As scientific terms like “flattening the curve” were used, clear explanations of epidemiology were helpful. Having a trusted physician to guide pandemic-related communication allowed faith leaders to maintain their focus on ministry.

Third, how do we resolve our perceived duty to meet as a faith community and serve those in need with the government mandate to not gather? Each of our three faith communities highlighted in this report followed directions of our state government. However, these decisions came with careful consideration of relevant doctrinal teachings (“requirements” of participation in group gatherings as well as of inter-personal service) [4] and a clear understanding of when conflicts between religious teachings and local mandates would prompt “civil disobedience” with allegiance to a “higher authority.” Clinicians were aware of health-related teachings within their heritages and explained facts in ways that reduced apparent conflict between divine and human decrees. Faith communities preferred to comply with the recommendation of a trusted physician friend rather than integrate medical and spiritual teachings on their own.

Fourth, how can we maintain our ministries but reduce the risk of viral transmission? As the pandemic persisted, faith leaders asked the authors' advice on adaptations appropriate for their members’ consideration. In addition to affirming online services and meetings and advocating for emotional and social support of the homebound, we provided advice about social distancing during outdoor exercise, specifications for volunteers sewing face masks, sanitization guidance for food delivered by volunteer shoppers to the elderly, and safety while willing adolescents helped the elderly connect to online resources.

In summary, as physicians embedded in our faith communities, we are in unique positions to interpret and explain medical facts in understandable and compelling ways to our faith community leaders and co-congregants. Our experiences demonstrate customized approaches to the pandemic but also illustrate common principles and themes that can inform other discussions involving medical professionals and faith-based groups. By providing advice as clinicians integrated in our faith communities, we fostered understanding of medical principles and implementation of effective health-promoting interventions.

Credit author statement

Stephen Merry: Conceptualization, Writing-Original draft, Writing-Review and Editing, Visualization; Rachel Havyer: Conceptualization, Writing-Reviewing and Editing; Rozalina McCoy: Writing-Reviewing and Editing; Muhamad Elrashidi: Writing-Reviewing and Editing; Philip Fischer: Conceptualization, Writing-Original draft preparation, Reviewing and Editing, Supervision.

Funding

None.

Declaration of competing interest

The authors declare that there are no conflicts of interest.