**6. Yoga and Pulmonary Health**

Because of the long tradition in Indian yoga of deep breathing techniques, a number of recent studies have assessed the potential benefits of yoga on patients who present with chronic obstructive pulmonary disease (COPD). Patients who suffer from COPD often experience airflow blockage and breathing-related problems predominantly due to inflammation, which can be caused by numerous factors. A question of central concern with regard to yoga's focus on deep abdominal breathing has to do with the attention to the heightened awareness in every breath as potentially benefitting patient breathing and health (Dhansoia et al. 2022).

In order to assess the potential effects of yoga therapy on breathing fully, a metaanalysis was conducted in 2019 which gathered data from 11 randomized controlled trials with a total of 586 patients. The methods of the various studies analyzed yoga interventions grouped by either yoga breathing-only or by complex yoga interventions with yoga breathing added to physical postures, meditation, and/or lifestyle advice. The results of this study concluded that yoga therapy that focused on breathing exercises had beneficial effects on patients with COPD and resulted in better lung function through the measure of their forced vital capacity (FVC), forced expiratory volume (FEV), and Peak Expiratory Flow Rate (PEFR). The results of the study concluded that yoga breathing techniques can be an effective adjunct intervention for patients with COPD, as well as a beneficial preventive measure (Cramer et al. 2019, pp. 1847–62).

Acute Respiratory Distress Syndrome and Pneumonia are frequent complications of COVID-19 and surgery in elderly populations (Chiumello et al. 2022). An analysis of "upper-body yoga" in elderly patients with acute hip fracture assessed the feasibility and efficacy of yoga therapy for a population for up to four weeks post-surgery (Guo et al. 2019, pp. 1–8). The study placed forty patients in a control group that undertook abdominal breathing training, while 39 patients were placed in the yoga group and provided a regimen of yoga-related upper-body therapy. The study showed that one patient in the control group developed pneumonia post-operation whereas none of the patients in the yoga therapy group developed pneumonia post-operation (a statistically insignificant finding), and the study also found that elderly patients who participated in more than four weeks of low-intensity "upper-body yoga" training suggested higher FVC, PCF, and daily living activity than those in the control group. The findings of this study not only help show how yoga therapy can help with respiratory function but also how it protects the respiratory system from developing pneumonia. Additionally, it lays the ground for the safety and efficacy of upper-body yoga in the acute phase of hip fracture surgery and subsequent rehabilitation as a viable therapeutic intervention (ibid.).

The above studies suggest that yoga could be an effective intervention in ameliorating several key challenges that elderly patients face when infected with COVID-19. It may assist in strengthening the immune system, which can provide prophylactic protection against contracting the disease in the first place. It likely strengthens the pulmonary system, the primary system affected by COVID-19, leading to stronger, deeper breathing, which in turn has a number of ancillary benefits. Finally, yoga may lower the rate at which fragile patients contract pneumonia, reducing stress while promoting overall mental health with much lower rates of PTSD.

## **7. Assessment of Community Yoga**

Do the benefits of yoga outweigh the perceived risks of practicing it in an indoor group setting during the pandemic? The relationship between the yoga teacher and the student, known as the *guru-´sis.ya* relationship, is often cited in the ancient texts (including the *Upanis.ad*, which literally means "sitting down near" one's teacher who imparts their knowledge) as fundamental to the success of the endeavor. Some traditions developing out of the Tantric modalities that underlie Hat.ha Yoga even assert that the transmission of yoga principles and practices cannot be effective without the establishment of this sacred relationship (Feuerstein 2013, pp. 11–13). The frequent claim that the teachings of yoga must be practiced and taught in person follows from these ancient teachings. The challenge in the current pandemic crisis (but in similar situations that are not difficult to imagine) is that the communal practice of yoga can create conditions that facilitate viral transmission due to heavy breathing in small, enclosed spaces. This introduces a tension in public health policy, namely that yoga may help combat symptoms of and boost immunity to COVID-19, but attempts to minimize indoor interaction during the pandemic impede the ability to practice yoga. Additionally, as a practice that has deep roots in, and is inextricably connected to, the Hindu religious tradition, restrictions on the practice of yoga might in some cases be viewed as a challenge to freedom of religion.

One study found that satisfaction amongst practitioners joining a yoga class online was lower than amongst those who attended in person in the four main outcome categories of mental health benefits, feeling physically satisfied, feeling focused, and feeling energized (Brinsley et al. 2021, Table 2). Another study suggested that there is more risk of injury to the student when practicing online because the teacher is not present to correct the postures (Sharma et al. 2022, p. 1). A further study has demonstrated that there is no respiratory inhibition when wearing a mask and performing various forms of physical exercise including yoga. Researchers found that the participants in the study had no difference in the time to exhaustion when exercising with or without a face mask (Shaw et al. 2020). Yoga practice can also accommodate an acceptable degree of social distancing, because the space needed between mats in order to provide the room for the practitioner to properly stretch and move their limbs has to be at least two arm lengths, or perhaps six feet. It may be, then, that the effects of practicing yoga in person, using masks in a well ventilated and socially distanced area, may outweigh the threat of iatrogenic disease while producing the mental and physical benefits that can keep practitioners healthier during this difficult epidemic.

There are other factors to consider as well when determining whether yoga should be practiced in person versus online during the pandemic. To fight off a pandemic, we need stronger, more resilient, and more productive communities, which can be achieved through community connectedness, which itself in turn is a byproduct of communal yoga therapy at studios, health centers/clubs, and rehabilitation centers (McGrath et al. 2017, p. 101). We have to remember that there are many situations in which the importance of being together in a physical place outweighs the risks of contagion, such as at hospitals. The health care workers have to come into contact with the patients in order to treat them, so the question then becomes whether a yoga instructor can be thought of in these terms as well. As a therapy that is recognized as having health benefits both by the National Center for Complementary and Integrative Health and the American College of Physicians (https://www.nccih.nih.gov/health/yoga-what-you-need-to-know) (accessed on 4 February 2023), it is clear that yoga instructors are important adjunct healthcare workers and should be treated as such.

Those who already live and work in congregate settings could readily find communal yoga to be a helpful tool for maintaining health. The most integral part of a resilient community during a pandemic is its healthcare workforce. Healthcare workers (HCWs) are already at a higher risk of suicide before a pandemic and at an even higher risk of suicide during a pandemic. Bismark et al. (2022) address how the pandemic magnified their pre-existing mental illness as well as issues in their personal lives such as domestic violence and financial struggles. During the pandemic, HCWs faced an increase in work obligations while facing depletion of the necessary medical resources. HCWs recommended that having a stronger sense of belonging would have been more beneficial to mitigate suicidal thoughts (Bismark et al. 2022, p. 113). Communal yoga can help provide HCWs' need for belonging and connectedness in order to quell thoughts of suicide or self-harm.

Communal yoga would not only be beneficial to HCWs but to their patients as well. In addition to maintaining HCW durability in the workplace, patients could benefit from direct access to yoga practice which has been shown to improve strength, balance, flexibility, and attention control as well as providing a greater sense of belonging, community connection, and the ability to move forward with their lives (Donnelly et al. 2020, p. 2482). Fall prevention programs that use yoga therapy have been studied for those who have Parkinson's Disease. In fact, one study, despite its small sample size, was able to find that the experimental group that received yoga therapy had a significant reduction in fall risk compared to their control group. Both groups experienced improvements in motor function, postural stability, functional gait, and freezing gait (Van Puymbroeck et al. 2018, p. 1). A study analyzing the WDEQ pregnancy-related anxiety questionnaire assessment also found yoga to be effective in reducing anxiety as a form of prenatal care (Newham et al. 2014, p. 631).

Prisons provide yet another forced congregate setting which might take advantage of in-person yoga practice. A review of the relevant literature related to yoga in prisons found that yoga helped alleviate aggression and violent behavior through its stress-reducing effects (Muirhead and Fortune 2016, p. 57). A systematic review on yoga for substance abusers found significant cessation of substance use by using yoga therapy alone or when using yoga therapy in conjunction with other pharmacological treatment modalities such as opioid substitution therapy (Walia et al. 2021, p. 964).

The above considerations lead us to surmise that for individuals who find themselves during a pandemic type situation in unavoidable congregate environments (such as various sorts of healthcare facilities, nursing facilities, and prisons), communal yoga practiced with masks and social distancing can be commended for disability rehabilitation, substance abuse rehabilitation, aggression alleviation, suicide prevention, fall prevention, prenatal care, and postnatal care and may be successful in maintaining or improving mental health and physical wellness. Public health policymakers might also consider programs that provide safe access to yoga by ensuring hospital prayer or meditation rooms appropriate in size and ventilation for yoga to be practiced with as little risk as possible.

#### **8. Public Health Policy Implications of Yoga Practice**

The evidence brought forward in this paper suggests that yoga practice can help to prevent or mitigate symptoms of COVID-19 and improve overall mental and physical health—with the caveat that additional research, maintaining rigorous experimental design standards with larger sample sizes as well as extended longitudinal and meta studies, needs to be undertaken. We have also just suggested above that in-person communal yoga practice has greater benefits and fewer adverse effects than yoga practiced alone at home, and, therefore, if people are already living in a congregate setting, then practicing communal yoga is likely to be beneficial even during a pandemic. However, if the research is more than suggestive that yoga interventions are efficacious, what public health policies might we consider appropriate to actively support therapies to enhance patient care and population well-being more broadly? Are there circumstances in which those who are not

already in a congregate setting ought to practice yoga in person? How might this compare to other spiritual practices?

During the very earliest days of the COVID-19 pandemic, and frequently later during acute surges of viral transmission, many religious communities shut down their places of worship and eliminated face-to-face worship and community events. In the United States, state governments generally argued for such mandatory closures on the basis of the Supreme Court decision in Department of Human Resources Oregon vs. Alfred Smith (1989) that if a law was enacted that encroached on religious liberty but did so for the public good and did not single out any particular religion for unequal treatment, then such policies could be construed as permissible under the US Constitution (Levison and Segall 2020, p. 1). In the earliest days of the virus before vaccines and therapeutic treatments were widely available, as well as in subsequent months where large gatherings were established as transmissible events, many early cases of mass contagion were traced to religious gatherings (Linke and Jankowski 2022, p. 1641). As businesses were gradually allowed to open at reduced capacity, some states such as California still required religious institutions to remain shuttered. Legal challenges mounted and the Supreme Court ruled that the religious institutions were being treated unfairly because other buildings were allowed to reopen at limited capacity (Breslow and Totenberg 2021, p. 1). Many yoga studios closed of their own volition during the height of the pandemic and others were forced to shut down due to government regulations. Many yoga studios were forced due to economic reasons to close for good, and YogaWorks, one of the largest chains of studios, filed for Chapter 11 bankruptcy citing the effects of the pandemic (Club Industry 2020).

Curtailing the spread of COVID-19 was, and remains, a public good. However, as effective barriers to transmission have increased, as vaccination and infection have become more widespread and effective in their protection against serious reinfection, and as the benefits of prohibiting all gatherings has been offset by various costs and burdens society incurs for practicing such a restrictive policy, there have been significant shifts in public policy.

This raises the interesting ethical question of whether—with the goal of combatting COVID-19 and advancing health in more general terms—it is better to allow communal religious practices or forbid them. It is important to note in this regard that many patients have positive outlooks toward physician involvement in spiritual issues, with 77% in one study saying that physicians should consider patients' spiritual needs and 37% wanting their physicians to discuss religious beliefs with them more frequently (King and Bushwick 1994). Many religious and spiritual practices besides yoga have been shown to be linked to increased mental and physical health (Linke and Jankowski 2022, p. 1641). It has been known for some time that regular churchgoers, for example, tend to have longer life expectancy and better overall health than appropriate control groups (Mullen 1990). What might account for this? Other than reducing stress, it is likely that participation in religious services itself is not the proximate causal event that brings about the improved health noted in studies. Rather, those who attend are likely in other settings to make healthier lifestyle choices, have less substance abuse, more secure friendships and family relationships, and follow doctors' instructions more carefully. This has led some to believe that going to a place of worship such as a church or synagogue even during the pandemic (and with some of the risks that it entails) may have tangible psycho-social or health benefits.

In spite of the fact that public health analysis with respect to social distancing, viral spread, and relevant mitigation has equated studio-based yoga practice with church attendance, there may be important differences between the two that justify how we support or restrict these practices in the time of a pandemic. In the case of yoga, it is the actual practice—not just attendance—that leads to the positive health outcomes. Though studies have shown that areas with lower attendance of religious services had lower transmission (Linke and Jankowski 2022, p. 1641), there may nevertheless be some benefits to one's health from attending yoga classes, if the various benefits that we have outlined so far in this article turn out to be sufficiently effective. A central question then becomes

whether the same effects can be obtained from doing yoga virtually with online instructors and whether the balance of safety with promoting health dictates that yoga should be practiced individually rather than communally in groups to avoid iatrogenic effects from yoga practice.

As the pandemic proceeded through its natural cycle over several years, many yoga practitioners continued to practice apart from their regular studio experience, setting their mats up at home and often participating in online yoga instruction. Such practice expanded significantly during the pandemic. Yoga equipment sales grew 154% during the course of the pandemic as many people sought to maintain this important part of their lives at home (Business Wire 2020, p. 1). Adriene Mishler is an example of a successful online yoga instructor. She uploaded yoga videos onto her YouTube channel Yoga with Adriene, and, within the first three months of the pandemic, video views went from 500,000 to 1.5 million views each day (Okamoto 2021, p. 1). However, as yoga instructor Amy Suplina notes, "The intimacy and reverence that occur in a studio are essential. The reason we teach yoga is that alchemy of having bodies together breathing and moving in a room, and seeing people, and connecting and sharing that experience" (Okamoto 2021, p. 1). We also noted above that the benefits of yoga when practiced at home through online instruction are not as robust as those that accrue when doing yoga in person energized (Brinsley et al. 2021, Table 2). To retain the noted benefits of group in-person practice during the pandemic, some private yoga studios held outdoor or rooftop yoga with proper social distancing in order to accommodate the needs of the community. (Similar sorts of arrangements were appropriated by various religious communities as well).

Amy Suplina's notion of the importance of practicing yoga in-person can be further evaluated in light of the fact that most people in America, regardless of the various preventive measures that were put into place, ended up contracting COVID-19 anyway. The government's strict mandated isolation requirements may not have reduced the overall number of people who contracted the disease but did become obstacles to preventive care involving religious practices such as yoga therapy. While, of course, practices such as wearing masks and keeping some distance from others are highly effective at preventing the immediate spread of COVID-19 and other similarly contagious respiratory diseases, the practical aspects of life are such that no one can be expected to actually stay away from others or wear a mask properly at all times in public. Even with all of the restrictions that have been in place, most people in America seem to have contracted the virus at some point during the pandemic. The Center for Disease Control reports that the total number of reported cases as of March 2023 was 103,672,529 (CDC Covid Data Tracker 2023). However, an earlier CDC study suggests that the majority of cases have gone unreported, finding in September 2021 that only about 1 in 4 cases since the start of the pandemic had been reported (Estimated COVID-19 Burden 2023). If these low reporting estimates are anything close to the actual reporting frequencies, this would suggest that almost everyone in America, knowingly or unknowingly, contracted COVID-19 at some point during the pandemic. The CDC also announced in April 2022 that at least 60% of the population had had COVID-19 at some point (Neel 2022), and at the time of this writing, almost a year later, the disease is still very much on the march, so the numbers must be considerably higher than that currently. Finally, we also see that there do not appear to be significant differences in the total number of cases between states with strict and lenient prevention policies. For example, California has particularly tough restrictions that include mandatory masking at healthcare facilities, homeless shelters, and jails, whereas Texas actually prohibits schools and local governments from instituting masking requirements at all (Markowitz 2023). Yet, at the time of this writing, California had a total case rate of 306,189 per million residents, whereas Texas had a total number of cases standing at 290,688 per million (United States Worldometer 2023). This suggests that while the masking and other provisions may delay the contraction of COVID-19 and flatten the curve that represents the case rate on a graph, they do not eliminate it. If masking is held to be important for attenuating the number of cases at any one time in order not to overwhelm the healthcare system, then one might also

add that yoga could help in this endeavor as well. Ventilator shortages and shortages in other healthcare resources have been an ongoing problem during the pandemic, and, as such, the benefits of yoga therapy that we have laid out could help keep some people out of the hospitals, even if they did not mitigate the actual spread of the disease.

The extremely high total number of COVID-19 cases as we enter three years of pandemic thus adds yet another layer of complexity onto the question of whether yoga should be practiced in person in such a situation. If people are highly likely to eventually contract the disease no matter what they do, then are the potential benefits of practicing yoga in the traditional and most effective manner, namely in person with an experienced teacher acting as a guide, worth the risk?

If the benefits to immunity function, as well as pulmonary and mental health are indeed as robust as the studies that we have highlighted here indicate, and any given individual is likely at some point to contract the disease, then it may be that the risk of contracting the disease during any given session of communal yoga practice is outweighed by the health benefits acquired by the practice of yoga. There are a few scenarios that could play out in this situation: (a) an individual could practice yoga with a mask in a communal setting and never contract COVID-19; (b) an individual could practice yoga communally and contract COVID-19 from others at the yoga studio; (c) an individual could practice yoga communally and contract COVID-19 from other places; (d) an individual could cease practicing yoga or practice it less effectively on their own and contract COVID-19; (e) an individual could cease practicing yoga and never contract COVID-19. Out of these possibilities, only (b) involves iatrogenic disease that emerged out of the communal yoga practice itself. However, even here, if the individual did not practice yoga, based on the above mentioned case rates, it is still likely that they would have contracted the disease elsewhere eventually, but, in this case, they would not have the increased resistance that emerges from yoga practice. Moreover, the full benefits of doing communal yoga would accrue to all of the individuals in cases a, b, and c. Partial benefits might accrue in case d and none in case e (although they would not be needed).

The cost–benefit analysis of doing communal yoga is therefore extremely complex and not as straightforward as simply avoiding yoga studios. Ultimately, it may be impossible to assess the risk properly because of too many unknowable factors, but these scenarios represent an attempt to take as many factors as are now known into consideration, and it is worth noting that of the five possible scenarios, in only one case (b), does it appear that communal yoga could cause more harm than good. However, even here, there is nothing to rule out the possibility that this individual would have later found themselves contracting COVID-19 elsewhere, even if had they somehow known they would have contracted the disease at the yoga studio and ceased attending.

## **9. Public Health Policy Proposal**

For those who are working remotely from home and are not already gathered in public places such as hospitals and prisons, the question of whether the benefits of communal yoga outweigh the dangers of being near others during a pandemic such as COVID-19 is, as shown in the previous discussion, very complicated. There are good reasons for these people to practice yoga in person because the benefits to any future contraction of the disease may outweigh the possibility that they will contract the disease at the yoga studio. However, while satisfaction with yoga was higher when practiced in person based on the study by Brinsley et al. (2021), it may be the case that to avoid iatrogenic effects, yoga practiced in isolation through video instruction can be recommended for those who are immunocompromised, elderly, or for other reasons must take the utmost caution with regard to exposure to the disease.

We would also recommend that, where feasible, yoga studios conduct their lessons outside in open areas. This is, of course, the easiest way to mitigate the spread of the disease while still experiencing the benefits of communal yoga practice with a live teacher. We also suggest resources be devoted to providing therapeutic access to virtual yoga as a federal program for those who are uncomfortable going to yoga studios in person, but we recognize that there may be some resistance to government involvement due to the concern that yoga has its origins in religious practice. However, the United States National Institute of Health (NIH) and the National Center for Complementary and Integrative Health (NCCIH 2022) have established stress-related initiatives and are considering ways in which yoga may be able to help with breathing-related diseases and future infectious threats just as the Ministry of AYUSH of the Government of India urged their people to protect their health by immune boosting techniques through yoga (Debnath and Bardhan 2020, p. 1). Despite its religious roots, yoga is nevertheless regarded as an allowable recipient of public funds and has received endorsement from the NCCIH (Black et al. 2018, p. 1).

### **10. Conclusions**

Yoga has been practiced in different forms throughout India for millennia and is spreading globally. In both its historic and contemporary settings, it has been viewed as a path from the confines of the body to ultimate salvation. Some strands of the tradition—such as Hatha and Vinyasa Yoga—use the body itself to achieve higher states of consciousness as well as to achieve esoteric powers through the practice of various techniques of breath and body control. Clinical research has suggested that some of these techniques have health benefits with statistically significant outcomes that boost immunity and pulmonary strength as well as improve mental well-being. The practice of yoga has been recognized by the NCCIH as a legitimate form of alternative or complementary medicine. Significant research is continuing into the health benefits of yoga. As such, there are possibilities to acquire funding to provide more access and information for the practice of yoga as seen by the sponsorship for Yoga Warriors (501(c)(3)) through the 2019 Mission Act (Reddy et al. 2019, p. 1592).

In future pandemics and similar cultural challenges, we recommend that national governments sponsor yoga practices through the implementation of communication and practices similar to that advanced by India's Ministry of AYUSH during the COVID-19 pandemic (Debnath and Bardhan 2020, p. 1). The United States government should designate outdoor spaces that are amenable to social distancing and promote such areas for outdoor and appropriately distanced physical activity. The peak of the recent COVID-19 pandemic produced the promising prevalence of rooftop yoga for aspiring newcomers as well as avid practitioners. For those who are immunocompromised and are unable to risk human interaction during a pandemic, there should be government assistance for free online yoga classes through the NIH-NCCIH or appropriate websites. The NIH-NCCIH should also promote their currently free published *eBook on Yoga Health* from their website during times of severe outbreak to encourage people to practice preventative self-care. Future editions of this publication should describe how yoga can help combat any new upcoming pandemic. For those who believe yoga to be a practice grounded in faith, and not just a secular endeavor, the government should ensure prayer rooms at healthcare and community centers and have social distancing in order to allow for this practice to take place.

**Author Contributions:** Writing—original draft, R.P.; Writing—review & editing, D.V. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Conflicts of Interest:** The authors declare no conflict of interest.
