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5.21.2020

Illinois COVID-19 Reopening and What I Think It Means for Combat Sports

 Disclaimer: What follows is not medical advice. The best way to avoid COVID-19 is NOT to train until herd immunity has been established or a vaccine discovered. This is a theoretical discussion and nothing more. Proceed at your own risk.

Let's start by being absolutely clear: we do not and will not have a treatment for COVID-19 in the foreseeable future. If you or your loved one gets a bad case of this the best modern medicine can do is support your body while we hope you recover. Second, a vaccine remains over a year away. Finally, we are weeks to months away from herd immunity, if we can even develop that with a virus that has rapidly mutated into several strains. If you want to minimize risk to yourself, your loved ones, your friends, and coworkers the only things that will do that are:
  1. Clean: Hand washing or sanitizing for at least 20 seconds before and after touching yourself, another human, or an object. If your academy were to open this would basically mean at the beginning of practice, before each round, after each round, and before leaving class. It also means showering thoroughly before and after practice. It means thoroughly wiping down each piece of nonlaunderable equipment with bleach wipes. So that’s a lot of sanitizer and bleach solution.
  2. Cover: Wearing a mask that decreases the spread of droplets. Not all masks are created equal so it needs to be a mask that blocks viral droplet particles. All masks are not created equal and masks are designed to protect others from you not you from them. We do not know if masks remain effective as we sweat and get them wet.  Note that exercise training masks and running masks contain filters that viral droplets go right through. They allegedly are rated for pollution and bacteria much larger than the diameter of a droplet. They look cool but they won’t do much other than provide an illusion of safety.
  3. Clear: Social distancing or being at least 6 feet away from other people. Thus the ultimate way to stay safe is to train by yourself. This is a great way to get stronger, more flexible, and better cardio. But it is not going to improve your technique or your timing. If your academy does open up strongly consider a single dedicated training partner and only training in classes of less than 10 people. If you are or live with some at high risk, don't train.
You are likely safer in an area with a greater volume of distribution, e.g. outside, than in a small volume of distribution, e.g. in the academy or gym.
The Illinois Reopening Plan is a regionalized 5 phase plan that can move us as a community closer to normal if public health indicators are favorable or reassert more restrictions if they are not. The plan uses cases, testing availability, and hospital resources (e.g. beds and ventilators) in predefined geographic areas. In the central part of the state we appear to be in Phase 2 with a good chance of moving to Phase 3 in June 2020. We don't need to rely on laypeople determining risk, the phases will shift based on public health data.
There is, of course, no specific instructions for combat sports in my state’s plan, the nearest things that we might be compared to are health clubs. This is a specious comparison, in health clubs, you can continue to social distance more than 6 feet, wear masks, and sanitize your hands between exercises while still getting a fulfilling workout. Combat sports like boxing, wrestling, muay thai, kickboxing, Brazilian jiu-jitsu, and mixed-martial arts however all involve core doctrines that include significant physical interaction and contact. USA Wrestling has released its Return to the Mat Guidelines, a phased approach that like the Illinois Reopening Plan avoids or minimizes organized, group, physical contact for the duration of time before herd immunity or wide-spread vaccine deployment. The Illinois Reopening Plan recommends masks and social distancing until the last phase. In phase 3 groups of up to 10 people can gather and in phase 4 up to 50 people with appropriate behavioral alterations. One-on-one personal training and small group classes may begin in phase 3.      
Reopening gyms and academies like they were before the pandemic is unrealistic before we have a vaccine or herd immunity. That said, these are small businesses that will not get sufficient support from the state or federal government. It is up to the martial arts as a community to save our gyms and schools. This may mean paying for classes at the same or reduced rate as instruction goes more virtual and classes are limited in both contact and population density. If we lose the societal checks on this novel coronavirus too early, academies and clubs will be the hot spots of their communities, the source of deaths for the old and the medically compromised. If we maximize social distancing with dedicated training partners, frequent hand sanitization, and mask adherence, we mitigate this risk. This means that practice will be a lot more hands-off and more often without interactions that we felt were the norm for our training. For example, as detailed in other plans starting with solo training and then adding partner drills at range (e.g. long-range stick or pad work) and forgoing body to body contact, e.g. knee play, wrestling or grappling until much later than anyone wants. It also means getting frequent testing, likely every two weeks as they become increasingly available and free. It means symptom checklists before each practice, likely completed on-line at a distance, and temperature checks at the door. It means a thorough cleaning of the gym and equipment before and after each session.
I do not believe that we are prevented from rolling, sparring, and other close-quarters work for the duration of the pandemic. However this will likely mean forming “pods” or small groups not including immediate family. In other words, it’s about finding one “monogamous" training partner that you will train with for the duration, either privately or in group settings. There is a two to three week “cooling off” period before switching partners to limit spread. Your risk is likely decreased if you only train with that person in a private setting, but with symptom checklists, strict hygiene protocols, temperature checks, frequent testing, and mask use. Masks are likely a custom made cloth mask that can withstand the rigors of training. Based on the Illinois plan I would not consider this sort of training until Phase 3 and it is likely more prudent to wait until Phase 4. Best case for Central Illinois that would be July. Any negative change in phase would place an immediate moratorium on training.
However, if this pod model means you quit your academy then we are destroying the art by eliminating the small businesses that are martial arts studios. We must balance our personal training needs by considering using pods while simultaneously supporting our academies and clubs. One way of doing this would be to run social distancing academy practices in parallel with pod classes virtually. Thus people who had access to private training spaces could work with their designated partner more closely without significantly increasing risk to others. Simultaneously those without a private training space could workout in a different fashion with alternate but still likely minimal risk. If things improve we could work gradually closer to how things used to be while realizing that they will never return to that baseline.
Stay safe.

5.07.2020

Commentary on Reopening Combat Sports in the COVID-19 Pandemic

Let me preface this with a little about non-combat sports me. I’m a doctor. An internist by training who now does mostly palliative care with some bioethics. So I’m trained to be an adult person doctor either in the clinic or the hospital. I have focused my practice in palliative care, the area of medicine that deals with the quality of life and wellbeing in people who have advanced, life-limiting illnesses. I see a lot of suffering and I see a lot of death. Obviously from this blog I have substantial interest and experience in combat sports including Brazilian Jiu-Jitsu, Jeet Kune Do, Muay Thai, and Mixed-Martial Arts. Yes these two interests seem widely antithetical but I’m complex like that.

I am NOT an epidemiologist, infectious disease physician, or public health expert. So this is my opinion on medical topics that I have some familiarity with but I am NOT an expert on. Sadly I do not know of any of these specialists who also train in combat sports, who could likely give us better guidance. I will further caveat this with that ANYONE who trains has a secondary gain in their gyms and academies opening up again. We need to acknowledge this implicit bias exists in any conversation where those who participate have a deep-seated desire to get back on the mats and into the ring. I know I do. I want to train so bad I can taste it.

You may be familiar with Dr. Chris Moriarty’s Guidelines for Opening Up Jiu-Jitsu Academies During the COVID-19 Pandemic. It is an interesting read. Dr. Moriarty has certainly put a lot of thought into this. But if I agreed with everything he suggests I wouldn’t be writing a commentary. I do suggest reviewing this document as it is clear that the intent is to resume training in Brazilian Jiu-Jitsu as safely as possible. I cringe a little bit at the use of the word “Guideline” as typically in medicine these are based on research and consensus opinion by a large group of experts rather than one person. I believe he is spot on with this being a phased approach with different activities being acceptable at different times. Personally, I would suggest following your state’s reopening plan rather than the federal plan as your state is more likely to police, fine, or incarcerate you if the case of any intentional or accidental wrongdoing. Also even in neighboring states, such as Illinois and Indiana, can have massively differed. I plan a follow-up discussing my state of Illinois and Indiana’s plan at a later date.

I agree with Dr. Moriarty that the first part of returning to our academies will involve careful planning and continued social distancing which makes practice largely composed of solo drill and conditioning, due to social distancing and in a mask to limit transmission. We know little about how this novel coronavirus travels through the air so we do not know the optimal distance for avoiding this kind of transmission. For example with the guess that each student requires 64 square feet that means that a 1000 square foot space can only hold 15 students. That likely means longer hours of operation to accommodate everyone and a lot of cleaning between classes. This may be prohibitive in reopening smaller academies in a financially stable manner.

When COVID-19 initially hit we all were inundated with fever being a ubiquitous sign of this disease. We are learning that fever is not as common a presenting symptom as we thought. This means using the absence of fever as an objective marker of who is “safe” to train with is likely spurious and a waste of time and resources. I do agree that a checklist to limit risk makes a lot of sense but will be difficult to realistically implement. As a clinician working in an area with community spread and with active COVID-19 cases within our hospital walls I witness abundant accidental behavior in myself and others that increase the risk of transmission. We would rapidly violate the checklist for everyone if we were aware and honest about their daily activities. We are not.

I live and practice in a community where rapid testing is available. Turn around is about 24 hours. However we don’t have enough testing swabs and medium to test people once or twice per week. Besides no insurance is going to pay for testing this often. And the risks of repeated use of deep nasopharyngeal swab sampling have not been tested. In other words, imagine having someone shove an extra-long Q-tip into the back of your nose, roughly at a distance into our skull where your ears create a line twice per week. No thanks. In addition, we don’t know what immunity looks like and we don’t know the meaning of what positive serum antibodies actually is. Positive antibodies likely mean you are immune to the strain that caused the antibody reaction but for how long and how well to other strains is unclear. Furthermore you don’t have to be infected and immunity doesn’t mean you cannot transmit COVID-19, it could just be on your hands or equipment.

Many reopening plans have included the use of 50% capacity, arguably as a way to help continue social distancing. That makes sense for fitness gyms where limiting capacity limits population density using equipment hypothetically making it easier for people to spread out. However limiting capacity makes less sense for combat sports, the entire point of which is to interact at close range and as a consequence of this lead to the swap of sweat, tears, snot, spit, and other mucus.
Dr. Moriarty does a good job of saying if you have risk factors, live, or work with people who do (such as healthcare staff) then training may be out of the question for you. We don’t know how to best mitigate those risks but we do know distancing ourselves from others decreases the risk of transmission. It is up to all of us to ponder as individuals what our decisions can do once we have more autonomy to do so.

I do not believe that training is closed to us until a vaccine is developed (and not simply because the development of a coronavirus vaccine has never been done before). I am saying that we may be better served by adapting state reopening plans to the specific conditions that combat sports have and look at the best way to mitigate risk. Dr. Moriarty has several good ideas for decreasing risk, some of which I believe are less than realistically achievable. I encourage more discussion on this topic to get the best answer for returning to the martial arts that keep us fit, sane, and make us better people.