ENO Breathe: how the English National Opera helped Covid-19 sufferers find their breath

Through its innovative ENO Breathe programme, English National Opera is assisting people suffering breathing problems and anxiety issues caused by Covid-19

ENO Breathe: how the English National Opera helped Covid-19 sufferers find their breath

In March 2020, I caught Covid-19. Fever, loss of taste and smell, profound fatigue, dry cough: the works. My life as a classical music journalist went on hold. Walking up stairs left me out of breath. Though unpleasant, I thought the illness manageable.

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Then, after a few weeks, it got worse. All I could do was lie utterly still in a dark, silent room, concentrating on breathing. Inhale, exhale. The paramedics and doctors eventually said I was over the worst: just rest, drink water, take paracetamol. Still, I was left with ongoing, often strange symptoms. It sometimes felt as if my body had forgotten how to breathe. That was terrifying.

Cue English National Opera (ENO). This is a story about artists and medics who pooled their skills in a new way to help Covid survivors recover. It started with the UK’s first national lockdown, when ENO closed the doors of its home, the London Coliseum.

In the weeks that followed, the company’s costume designers swapped Puccini for PPE, and made scrubs and protective equipment for medical workers at Imperial College Healthcare NHS Trust. By June, word was getting out that for a good proportion of those who caught coronavirus, irrespective of its initial severity, the illness stretched out for months. So I was far from alone. Sufferers soon coined the term ‘Long Covid’, embracing a dizzying array of symptoms. Common among them, as reported in the National Institute for Health and Care Excellence (NICE) guidelines, are breathlessness and anxiety.

‘When we pare opera back, it is rooted in breath,’ explains Jenny Mollica, director of ENO Baylis (the company’s outreach programme). After hearing about Long Covid, Mollica started talking to her contacts at Imperial: ‘We had a hunch that we might have an interesting skillset to offer.’ ENO Breathe was the result.

Nearly a year since its pilot, this social prescribing programme has worked with 300 people who caught Covid, 81 per cent of whom say that their breathlessness has improved. Eighty-six per cent reported that the scheme has had a positive impact on their anxiety, while 90 per cent said it’s benefited their overall wellbeing. In January 2021, the programme was rolled out nationwide and Covid sufferers across the country are now singing their way back to good health.

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One participant, Sheeba, also caught Covid in March 2020. Her symptoms were fairly mild at first, but she developed pneumonia and was whisked into hospital. ‘What was shocking,’ she recalls, ‘was that when I got home, after two weeks I still couldn’t get out of bed. I had fatigue and breathlessness. I called my GP, asking “is this normal?”, and they said, “this is a new disease for us, hopefully you’ll be fine”.’ But after three months, Sheeba was still stuck in bed, and her GP was out of advice, so she struck out alone. ‘I found out that Imperial Healthcare Trust was looking for volunteers for a post-hospital Covid study, and that’s when I found out about ENO.’

The study Sheeba enrolled in, as one of 12 participants, was ENO Breathe’s pilot programme. Over the summer Mollica had been working hard with two leading specialists – Dr Sarah Elkin, a consultant in respiratory medicine at Imperial, and Suzi Zumpe, a singer, educator and facilitator – both of them masters of the art of breathing. Together, they created a six-week online course of one-hour sessions that teaches participants how to breathe properly again.

Medicine and music meet in a series of fun, imaginative breathing exercises and beautiful lullabies. Music is the magic ingredient here, and technical physiological terms are replaced with poetic words and vivid images familiar to singers. ‘When you breathe to sing, it’s inextricably linked with music and emotion,’ says Zumpe. ‘It’s really different to thinking “so I take my breath in, my diaphragm drops, what are my intercostal muscles doing?” and so on. Singers are used to distilling the physical process into a single thought.’

Before enrolling on ENO Breathe, patients have to meet strict criteria at a Long Covid clinic after a GP referral. Not everyone suffers ongoing symptoms for the same reason, and untreated alternative causes have to be ruled out. ‘ENO Breathe is there for people with nothing abnormal going on on any scans, but who really remain severely impacted in an ongoing way. It’s about getting them back to wellness more quickly and accelerating their recovery,’ says Mollica. Tanya, another casualty of the first Covid wave, is a case in point. As her recovery dragged on into 2021, she still couldn’t breathe well and she noticed problems with her voice. ‘I sounded husky a lot of the time, and I couldn’t sing anymore. It’s not like I sang all the time but I’d always enjoyed it. It felt like a big loss.’

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Once participants have signed up, they are sent a welcome pack (including a straw, more of which later) and have an introductory chat with the course leaders, Suzi Zumpe and Lea Cornthwaite. Sheeba was initially wary, as she’d only ever really sung Bollywood songs in the shower. ‘But I remember, I told Suzi I was tired, and she was the first person who gave words to my thoughts. She said, “you know, you’re feeling tired because of breathlessness”. This was like the penny dropping. It made complete sense. I’m not getting enough oxygen into my cells and that’s why I’m feeling tired. That’s what hooked me, and the rest is history.’

I find out for myself when I dip into an online ENO Breathe session. Lea is taking the group, and he guides us through gentle stretching and breathing exercises that include visualisations and humming. Then those straws are brought out so we can blow bubbles into a glass of water – a technique he calls ‘straw phonation’. Next, he breaks down the music of Jessie L Gaynor’s lullaby ‘Baby’s Bed’s a Silver Moon’ line by line, accompanying at the keyboard. It’s surprisingly soothing and uplifting, singing a lullaby to my laptop, and I can feel myself engaging fully with my posture and breath. Later in the hour, we turn to the lullaby ‘Summertime’ from Gershwin’s Porgy and Bess. ‘The way it paints the picture of summer is exactly what we needed,’ reflects Sheeba; ‘a light at the end of the tunnel.’

‘Our connection to lullabies is pretty primal,’ says Zumpe. ‘Wherever we’re from, whatever culture or background, whether we consider ourselves musical or not, deep inside we all know what a lullaby is. Musically they are nourishing and satisfying. There’s something about them that holds the promise of morning. They are about hope.’ Each week, the group works on a different lullaby. As well as the Zoom session, participants can explore a set of online resources, including recordings of lullabies made specially for the project at The Coliseum. ‘What I really liked was that at first I found each lullaby really hard, but I practised all week and got better at it,’ says Tanya. ‘And I’d find myself randomly humming, and it turns out that humming is really good for your throat as well.’

Even after just one session, I’ve picked up helpful techniques for my recovery. ‘These are simple tools,’ Zumpe explains, ‘but if you’re in a moment of profound breathlessness, they anchor you and physically change what’s happening, rather than exacerbating it. If you slow your breathing down and extend your exhalation, you have access to your thoughts in a different way. You lower your heart rate and you engage the parasympathetic nervous system – which is the rest-and-digest element – rather than getting caught in the fight-or-flight response, which is part of over-breathing.’ When your breath is out of kilter, that can lead to anxiety. ‘Anxiety isn’t something you can think your way out of, because it’s not a cognitive choice. It’s a physical response,’ she explains. ‘But you can physically influence how you then feel about it.’

‘I found myself smiling and laughing a lot,’ says Tanya. ‘Every now and then Lea would say, right, unmute for straw phonation – when you try to blow bubbles evenly in the water. It would just set me off, all these weird sounds! And there was a fabulous exercise called spell-casting, which was a set of sounds and hand and throat movements, and you cast a spell, magic up a cake, swallow it… that one is a really fun one to do.’ In fact, the programme has been so successful that participants asked for more. ENO responded with the fortnightly Twilight sessions for anyone who has completed ENO Breathe to practise breathing exercises and learn more lullabies.

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With current funding to help up to 1,000 patients, ENO Breathe has been a true success. Imperial and ENO are running a randomised trial, results due this autumn, that will give further data; but already medical and arts organisations around the world are set to run similar programmes. In Cardiff, Welsh National Opera is about to launch its own version, while over in California LA Opera has been running a pilot scheme. But how do ENO Breathe alumnae feel about it? Is Tanya’s voice any better? ‘Yes,’ is her confident reply; ‘I can sing again now. I’m still a bit croaky when I talk, but I can sing.’ And Sheeba? ‘With all the exercises, I could see the effects at the end of six weeks,’ she says. ‘They dissipated the anxiety and panic. I didn’t actually know I had it in me to sing. Apart from feeling better in terms of my breathlessness, there’s a high to discovering yourself in a different light. It’s been a beautiful journey of self-discovery.’