What a Song and COVID-19 Have in Common: A Podcast with Lucinda Halstead, MD

Dr. Lucinda A. Halstead is the Vice Chairman for Resident Education in the department of Otolaryngology, Head and Neck Surgery, and the Medical Director of the MUSC Evelyn Trammell Institute for Voice and Swallowing. Dr. Halstead founded the MUSC Voice Center in 1987 to support research and advanced care in laryngology, swallowing, voice, pediatric otolaryngology, and performing arts medicine. In 2000, she became the medical director of the Evelyn Trammell Institute for Voice and Swallowing.

She is the laryngologist for the internationally renowned Spoleto Festival USA and the president of the Performing Arts Medicine Association.

Read The Transcript

[00:00:13] Lynch-Reichert: Hello, everyone, and welcome to our last Medical University of South Carolina Science Never Sleeps Podcast for 2020. It has been quite a year, and we thought our December podcast would begin with a soothing and beautiful musical piece in the spirit of the holiday season. You are listening to "Sing We Now of Christmas," an original composition by Susan Conant, performed by The Robert Taylor Festival Choir here in Charleston, with a CD of the same name recorded and released by Robert LaPorta's MSR Classics label. But it is not just by chance that we offer this lovely vocal rendition.

It is a segue to a very fitting and timely podcast with our guest Dr. Lucinda A. Halstead, Vice Chairman for Resident Education in the department of Otolaryngology, Head and Neck Surgery, and the Medical Director of the MUSC Evelyn Trammell Institute for Voice and Swallowing. Dr. Halstead founded the MUSC Voice Center in 1987 to support research and advanced care in laryngology, swallowing, voice, pediatric otolaryngology, and performing arts medicine. In 2000, she became the medical director of the Evelyn Trammell Institute for Voice and Swallowing She is the laryngologist for the internationally reno Spoleto Festival USA, and president of the Performing Arts Medicine Association. Welcome, Dr. Halstead.

[00:01:46] Lucinda Halstead, MD: Thank you, Loretta, it is an honor to be here.

[00:01:50] Lynch-Reichert: I mentioned that this is a timely podcast, not only because it is a season of holiday cheer, and singing only sweetens the joy, but because the research with which you have been engaged has much to say about how COVID is spread. It was and is a massive undertaking. Would you share a little bit about this study and how it came about?

[00:02:10] Halstead: Absolutely. First, I should like to clarify that my role in the aerosol study has been primarily that of disseminating information to performers via webinar sponsored by Performing Arts Medicine Association, the National Association of Teachers of Singing, and the British Association for Performing Arts Medi Additionally, I have communicated this information by phone and email to my patients who are performers, and my performing colleagues at educational institute that range from elementary schools to university programs. Also, to my delight, I have been fortunate to exchange ideas with some of the study co-chairs and principal investigators during this study. The exchange of ideas, I hope, has benefited all of us.

[00:02:58] Lynch-Reichert: Dr. Halstead, I'm going to stop you for a moment and ask so this is an international group of scientists looking at this particular study, is that correct?

[00:03:09] Halstead: Yes, it is. It is the most amazing piece of research in a long time. The study is actually entitled The Unprecedented International Coalition led by Performing Arts Organizations to Commission the COVID-19 Study. Before I go into the details of who is conducting this I would like to give you just a little bit of background as to why this study was important. As the pandemic started, it became apparent that the virus might be transmitted by aerosolized viral particles, as evidenced by multiple super spreader events worldwide involving choirs. The first one that we had in the United States was in Washington State, where no masks were worn. Among 61 persons who attended that March 10th choir pr one person was known to be symptomatic of some sort of viral illness, which later was identified as COVID. Subsequently, they had 53 choir members identified, including 33 confirmed and 20 probable cases of COVID-19. Three of the people who became ill were hospitalized, -and two of them died.

[00:04:25] Lynch-Reichert: That's horrible.

[00:04:27] Halstead: Yeah, it was very, very tragic. This two-and-a-half-hour singing practice, when they studied it, provided several opportunities for droplet transmission and fomite transmission, meaning between inanimate objects, such as books, chairs, music. These included members sitting close together and sharing snacks, stacking chairs together, but most importantly, they were not wearing masks during the rehearsal. Thus, it was postulated that the act(unintelligible) might have contributed to the emission of aerosols and the infection of the choir members. Other outbreaks had already occurred worldwide, including choral rehearsals in South Korea, and in retrospect, on in London in December of 2019, where one of the choir members had recently visited Chi and came back and then attended a choir rehearsal.

So, looking back in the scientific community as to what evidence there was that viral transmission could occur through aerosolized particles. To our shock, there really was only one article that was published in 1998 pertaining to the spread of tuberculosis in a church choir where loud singing, of course, was being performed but that the transmission of tuberculosis occurred in a population that historically is not at risk to contract tuberculosis.

[00:06:06] Lynch-Reichert: That's really interesting. So, there was not—of course, no one knew at the time, in late December and then early in 2020, what exactly we were dealing with, and no clue that singing would be a transmission for the virus. It's interesting, I guess they were doing a literature study or something, and that's how they found out about the TB, or how did that come about that they looked at that and said, "Oh, there might be a connection here"?

[00:06:35] Halstead: So, that was a case report of this outbreak of tuberculosis in a choir, and that was the first time that aerosols actually had been mentioned in association with singing. Again, there have been other studies later on that associated the possibility of loud talking, but not singing, as increasing aerosol generation from a person.

[00:07:08] Lynch-Reichert: Okay.

[00:07:09] Halstead: So, the reason that it became paramount at this time, of course, is that, if we think about viral transmission by singing and through the bells of wind and brass instruments, it becomes a tremendous public health issue. It affects religious gatherings, theater and performance venues, but most importantly, it affects the musical education of our children, who are our future artists. So, that leads us to the development of The Unprecedented International Coalition led by Performing Arts Organizations to Commission COVID-19 Studies. This was just a phenomenal event. It was organized by the College Band Director National Association and the National Federation of High School Bands, which are headed by Doctors Mark Spede and James Weaver and they commissioned aerosol experts to develop a study to look at instruments, specifically the wind and brass instruments, singing, acting, and dancing, and, most importantly, what kinds of mitigations you could put in place to prevent these aerosols from infecting other people and other performers. The study was really a giant GoFundMe, in that they reached out, they did not go through a federal grant request. They said, "This needs to happen now," and they reached out to art organizations and had over 100 organizations contributed. The first $125,000 was raised within three weeks, and the total of $325,000 was raised within about eight weeks.

[00:09:00] Lynch-Reichert: I think that's phenomenal, and that really does speak to the desire of the performing arts community to want to continue to do the important work they especially, as you noted, for children, and that they took the initiative. They didn't wait around, they said, "Let's figure this out now so we can continue the great work that we do," so I applaud them for that. That really is wonderful.

[00:09:26] Halstead: It was just so, so amazing, the outreach and enthusiasm of the performing arts community. I think, most importantly, that reflects the passion and the personal desire of these artists to perform. I will tell you that, time and again, my patients say when they can't perform that they feel like that their soul is dead. That their sense of self is completely destroyed, they have no identity. So, for performers, singers, instrumentalists, without this artistic expression, they feel that they've really lost a good portion of their identity. So, they were very lucky, because they were able to reach out to two aerosol experts, Dr. Shelly Miller at the University of Colorado Boulder, and Dr. Jelena Srebric at the University of Maryland. And these two ladies should be commended because they were able to bring their labs out of lockdown, complete an IRB approval, and design parallel studies to verify the findings of each of their laboratories within about four weeks.

[00:10:43] Lynch-Reichert: That is incredible. For those who don't understand how the research process and indeed because of the COVID-19 lockdown of research laboratories, that is tremendous speed on their part to do everything correctly to be able to get up and running, and make sure they have approved research study. So, again, it just speaks to the passion of everyone engaged in this project. What were the findings that came out of this study, or at least the findings to date?

[00:11:15] Halstead: So, the finding to date is that aerosol emissions do occur and are increased by loud singing and through the bells of most wind and brass instruments. So, they then looked at what kind of mitigations would be effective in decreasing that aerosol spread. The biggest one is wearing masks. So, the mask will block most of the forward aerosol transmission, and what is not contained by the mask leaks mostly upward around the nose toward the ceiling, and a little bit out the side, versus forward towards your colleagues. We have found that the woven surgical mask, the regular ones that we see most people wearing these and especially our performers, will block about 64 percent of the aerosol. So, what they found is, with wearing the mask, and then distancing circumferentially the singers and the instrumentalists six feet apart, it was very, very effective in decreasing transmission.

[00:12:26] Lynch-Reichert: Can I stop you one moment there? What I was just thinking as you were explaining how they were beginning that mitigation process is, and perhaps you'll speak to this more later, is when they're required to do this for safety/health reasons, does it have an effect on the musical output?

[00:12:47] Halstead: Yeah, I can talk about that. These mitigations are actually-- That's part of the study, is to figure out what you can put in place that has the maximum amount of removal or blocking of aerosols, but does not degrade the sound of the instrument.

[00:13:07] Lynch-Reichert: Perfect.

[00:13:12] Halstead: So, the three-layer surgical masks are great because they closely cover the nose and chin, and they are recommended for singers. However, for singers, this is a real challenge, because when they breathe in, the mask is sucked up against their mouth and makes it very, very difficult. Plus, having the force of your breath coming back at you while you're singing can be very challenging. So, multiple mask designs are being studied by the Coalition to see which ones might be the best. I can already tell you that the singers have been extraordinarily inventive.

[00:13:52] Loretta: (chuckling)

[00:13:57] Halstead: But with all of these ideas of safety in mind in terms of mask fit, three layers, or N95 material, even if it's not completely fit, as we call, fit tested for surgery, to help mitigate viral transmission in church choirs and in the educational setting. So, that's what they're doing, they're looking at, for singers, these different kinds of masks to try to find something that's ideal. The same is going on with instruments. They have looked at different bell covers that make it still easy to play, but block the aerosol transmission. They have looked at how the instrumentalists can interface with the instrument, which is putting the mouthpiece into their mouth without having a lot of transmission. So, what they've designed, and seems to be extremely effective, as we can talk about in a minute, is that the instrumentalists will wear two surgical masks. The one closest to them will have a horizontal slit so they can get their instrument into their mouth, and while they're playing, that is the only mask that they're using.

However, hooked on their ear and when they're not playing is an intact surgical mask, so when they're sitting, they're just breathing and waiting for their turn to play, they have this extra mask that is blocking aerosol flow. So, the other things that they've looked at very, very carefully is environmental mitigation. I will tell you that a lot of our local college vocal programs are using these mitigations. Specifically, limiting performance time, or lesson time to 30 minutes, and then changing space. So, the reason that one wants to do that is that, with the leak around the mask, there is going to be aerosol that's disseminating through the room.

Their recommendation, based on their knowledge of aerosol transmission, or potential for infection, is that, after 30 minutes, there should be the possibility of enough aerosol in the room that we need to have a time to clear it. So, the 30 minutes is really based on the fact that most commercial buildings have a two-to-three air exchange rate per Hour. So, that means that it's anywhere between 20 and 30 minutes. We know that your air exchange, for example, is three exchanges an hour, then the air in the room is exchanged every 20 minutes. So, after 30 minutes, what they recommend is that everybody leave the room, you wait for 20 minutes, and then you can go back into that room, and hopefully what you've done is you have another room that you can go into and continue your lessons or your rehearsal.

But most of the colleges are doing video voice lessons, or outdoor rehearsal, and again, moving the venue. Even outdoors, they recommend that you move the venue after 30 minutes. However, one of the webinars that we did, sponsored by Performing Arts Medicine, was bringing it indoors, because now it's cold outside. And the airflow, again, in the performance space is very important. If you look at the website for the Coalition, they talk a lot about the air exchange rates, HEPA filters, and ultraviolet light. All of these things can also help decrease and kill the virus. So, these are some very important things. Additionally, again, Dr. Srebric has been very, very interested in trying to see if there's other kinds of mitigations they can use to help protect, and blow air away from singers so that they don't have to be masked. She shared with us one of her--she said, "This is my first approximation. I just used what I had. "She has a singer sitting at a table with two box fans, one on each side, blowing the aerosol away. She says "This is just what I had, and obviously you can't hear the singer singing because of the noise of the box fans." But it's great that they are looking at these kinds of things to help our singers be able to perform. If we could find things that they could do so that they could be in a theater-type interactive performance would be fantastic.

[00:19:18] Lynch-Reichert: Indeed, necessity is the mother of invention, no?

[00:19:23] Halstead: Yes, yes. So, I think the thing that I found very, very exciting is that people go, "Well, is this really important. These mitigations actually do work. Dr. Spede shared with us some of the things that he's been monitoring in band and orchestral practices, and there has been an incident where two of the clarinetists, and I will say that clarinets are one of the highest aerosol emitters of the wind instruments, were COVID positive during the practice. One of them was completely asymptomatic, and the other had been feeling a little crummy and went to the student health center and was told that he didn't have COVID and they didn't test him. Later on that evening, he felt worse and went to the emergency room and was COVID tested and was positive. No student in that orchestra was infected by COVID.

[00:20:34 Loretta: Because of those -mitigation processes--

[00:20:38] Halstead: Because of the mitigations. They were wearing the masks, they were doing the bell they were observing the time constraints, and no viral transmission occurred. That is huge because that means that we can have limited but safe rehearsals for our students. This will really help all of our young artists not lose their skills. One of the things that was brought up in the British Association of Performing Arts Medic was a study where they showed that musicians, high-level musicians, after two weeks of not doing anything, like no singing, or no instrumental practice, had a significant degradation in their skills, and it took them a long time to recover.

[00:21:28] Lynch-Reichert: Wow, that's incredible!

[00:21:30] Halstead: So, only two weeks, and you can have, for a high-level performer, a significant degradation in their skills.

[00:21:41] Lynch-Reichert: One of the things you noted is the study designers were very centered on making sure that they found some solutions, but as you noted earlier, talking about degradation, not degrading the actual sound of the performance. Is that correct?

[00:22:00] Halstead: That's correct. They've tried multiple things, especially with the bell covers. There were some that had very heavy material, and that was not good for the sound. What they noted was that they could have a lighter material bell cover and it did the same thing. They went even as far to having a very, very thin bell cover, which was essentially nylon pantyhose that they put over the bell. It was effective, but because it stretched after a while you could never guarantee the effectiveness. But now, these bell covers that they're recommending are commercially available for bands.

[00:22:53] Lynch-Reichert: That's wonderful.

[00:22:57] Halstead: It's just so, so exciting. Again, for singers, looking at the masks, looking at airflow in the performance space is really very critical. They are working on that, which is very exciting. It's hard, even for dancers, to work with masks. Actually, one of my colleagues is the physician for the Rockettes. They have them practicing with masks at home. They're just starting to bring them back into the theat to do some rehearsals. There's lots of different mitigations that they us in terms of having them come with their street clothes over their leotards so that they don't have to go into a changing room and have that locker room experience that you usually have backstage. They each have a little area to put their street clot and they just take it off, leave it there, do their dancing, go back, put it on, and leave the studio.

[00:24:09] Lynch-Reichert: I can imagine that that would be a challenge, but they're probably grateful for the masks because all performers, it's an expressive discipline. Even when you're dancing, your face is still part of that whole performance, so I would imagine that is rather challenging to them. And yet, they still-- I hope the Rockettes are able to do something phenomenal during the holiday season.

[00:24:32] Halstead: Well, I think they're looking very seriously at it, or, if not now, for next, this summer. But it is a problem. One of the things that we really have talked about is the fact that you can't see the lower third of the face with the masks. There are some translucent masks. All of those things are being looked at, but I don't have any of that data-right at the moment.

[00:25:03] Lynch-Reichert: Okay.

[00:25:05] Halstead: I think that all of us are really excited that there have been, now, vaccines that are approved for use, at least in England, and soon in the United States, the Pfizer and the Moderna, and potentially the AstraZeneca vaccines. This, of course, will be phenomenal to give everyone protection so that we could eventually move to a maskless performance. But people need to realize that that's going to take many months if not over a year to get enough people vaccinated so that it's safe to take the masks off.

[00:25:51] Lynch-Reichert: It's true, patience is in order, even as we find some wonderful solutions to help us get through these hard times. This is such an important study, and the results are quite interesting. I believe they are transferrable to all sorts of other including courtrooms, classrooms, on the athletic field. I'm really excited about what you all are doing, and even some of the commercialization of some of the devices coming out now. I think that a lot of people will really want to know more in-depth about this unprecedented research study, so we are going to share links to the video conversation with the lead researchers, and a video on the viral transmission to our audience. That will be part of the package that we send out to our audience. Everyone will have the opportunity to read more in-depth about this and understand even more how those aerosols really do spread quite a bit without a mask on. So, thank you very much for that information, Dr. Halstead

[00:26:55] Halstead: Just to corroborate what you've just said, they have looked at-- because again, this study was really primarily geared to putting students back in the classroom and performing in the classroom, but they also said these are some things that teachers who are not performing, or doing band or choir, can also use. The recommendations for a classroom, again, is that 30-minute contact, and then a change of venue. However, they recommend that the teacher be mic’d, so that they can only speak, or they can preferably speak, in a conversational tone versus projecting like many teachers have to as they project across the classroom. Additionally, when students ask a question, they were asked, the recommendation is to, again, ask your question in a very conversational tone without a lot of increased volume.

[00:28:06] Lynch-Reichert: That's very good advice, actually, very thoughtful. So, switching lanes a bit, tell us more about the Evelyn Trammell Institute, please.

[00:28:14] Halstead: The Evelyn Trammell Institute for Voice and Swallowing is actually--the goal of our institute is to deliver state-of-the-art care for patients with voice and swallowing problems. We achieve this by participating in research to advance the knowledge in both the field of voice and the field of swallow Not only do we participate in that research, we're very active in training medical and allied health professionals in techniques of voice and swallowing therapy so that they can help us with new ideas to advance scientific knowledge.

[00:28:53] Lynch-Reichert: It's very interesting, the Evelyn Trammell Institute for Voice and Swallowing is not only for the performing arts it's for everyday people. I'm thinking about the elderly, who especially are confronted with issues of swallowing. Is that true?

[00:29:09] Halstead: Yes, they have both voice and swallowing issues. As we age, we lose muscle mass and muscle tone. Although it seems almost counterintuitive that since we talk and we chew and swallow all the that as we age that those muscles would fail us, but you actually do lose strength in these muscles, so that there are many exercises for both the voice and also for swallowing to strengthen the muscles of the tongue and the pharynx the respiratory system, so that you can restore and build back strength to swallow effectively, or to speak loudly. And especially for elderly choir members to develop enough breath support to actually sing more loudly without abnormal compensations with accessory muscles of the neck, so that they sing clear and loud like they did when they were 20 versus in a tight sort of strained way that often happens when you're compensating for breath.

[00:30:26] Lynch-Reichert: Oh, that's good news. I'm very happy to hear that. Tell us some more about the common vocal issues you deal with as medical director of the Trammell Institute.

[00:30:36] Halstead: One of the most common things that I see is overuse. These performers perform all the time, so as they're singing loudly and their vocal folds are vibrating together, the edge of the vocal folds that contacts can become a little stiff just from continual use. That can sometimes lead to them doing abnormal compensatory maneuvers with excess tongue tension, more tension in the neck, and from that develop nodules or polyps. Sometimes it also just exacerbates some technical issues they have from incomplete training in whatever particular vocal style that they're doing at that particular moment. That's probably one of the most common things is that, and then the nodules and the polyps. But a lot of it is also, especially harkening back to the elderly, a lot of their problems can really be a disassociation of the breath to the vocal folds, so that they don't have that power coming up to vibrate the vocal folds, what we call subglottic pressure, because they've disengaged that mechanism. They disengage it mostly because there's, again, the degradation of the muscle tone in the chest wall and the diaphragm. But the other thing that is a huge problem nowadays is the forward head posture that we all have because of our screens.

Our phones, our iPads, our computers. Studies have shown that just putting your head forward about three or four inches, which is kind of what you do when you look down at your cell phone, you decrease your lung volume by 30 percent. What happens with that if you're sitting there-That's why when they want singers to be standing up straight and put their music out in front because if they have their head down here, they lose 30 percent of their lung volume. Then they have to use excess pressure of the accessory muscles of the larynx and neck in order to generate that pressure to get the vocal folds to vibrate and produce sound at the level that they want to produce

[00:33:22] Lynch-Reichert: I bet folks have-- I'm sure folks have not even thought about the effect of posture. Back to what our parents told us,-"Sit up straight!"-Sit up straight.

[00:33:36] Halstead: Yeah, our biggest technical advances are actually, in some ways, some of our biggest enemies in that it really has limited the ability for people to breathe, and to breathe normally, or breathe fully rather. I see that a lot in my aging patients. My residents can tell you I'm constantly sort of putting my hands on their ribcage and say, "Take a deep breath." They don't know how anymore, and so we sort of have to talk about that. It's very, very interesting.

[00:34:15] Lynch-Reichert: It truly is, it truly Is. I would suggest to you maybe a little yoga would help out with our everyday lives and breathing properly to save our vocal chords and our throats.

[00:34:27] Halstead: There is research out there that one of our PhD students did with our aging patients who had very thin vocal folds, known as vocal fold atrophy. We looked at inspiratory muscular training as being a way to recondition the respiratory mechanics so that they wouldn't need to have a surgery to augment their vocal folds. That was very successful. Additionally, the same type of inspiratory muscular training is used to actually tighten the lower esophageal sphincter to help prevent reflux. These are prospective, randomized studies that have been done to verify the efficacy of this. For people with reflux, they actually did the pH probe down the nose for 24 hours and the manometry probe to measure the tightness of the sphincter before and after they completed the training, and noted that it was very effective.

[00:35:33] Lynch-Reichert: That is, I have to say, that is one of the reasons why we do the Science Never Sleeps because not only does your institute offer information or solutions for folks, they continue to study and learn what are the best innovations to move forward the practice and to help their patients. And I think that what you just said is a highlight of why an academic health center like the Medical University of South Carolina is so important to the health and well-being of our ci We don't just offer regular clinical practice. We offer state-of-the-art based on the research of our faculty and the residents, and I think that's outstanding. Over your vast career, what are some of the most surprising clinical innovation that have been discovered regarding how singers protect and manage their instrument, the vocal chords?

[00:36:28] Halstead: One of the most fun and surprising things that has become very much incorporated into vocal pedagogy is a technique called straw phonation. Straw phonation basically is a way for singers to vocalize on a vowel, but instead with the straw in their mouth either open to the air, but often with the other end in about an inch of water What happens is it prohibits them from having excessive tension in the tongue and in the neck. It takes away these compensatory measures and allows them to vocalize very freely. If they're having trouble, for example, transitioning from their chest voice up into their head voice because they end up tightening at that transition, which is very difficult, it's a very complex muscular interaction. By releasing that tension, they learn how to easily ascend the scale without that tension. It can help them build their range. It can help them, again, with the register transitions. Also, because this technique causes a very high amplitude but very low-pressure rubbing of the vocal folds together, it also massages stiffness out of the vocal folds.

[00:38:05] Lynch-Reichert: And you're talking about a straw like a sipping straw?

[00:38:09] Halstead: Yeah, like a Starbucks straw.

[00:38:10] Lynch-Reichert: Hm, very simple!

[00:38:14] Halstead: Yeah, but we prefer it to have a bend in it, so that they stay aligned, and they get out of that forward head posture. I will say the caveat about that is that people shouldn't just go out and try it, especially if they have concern about a vocal problem. The voice teachers who are using this with their students are already sure that, by hearing their students and knowing their students over time, that they don't have a lesion on the vocal fold, like a polyp or nodule, okay? If they thought they were having that, then that's-- I see plenty of them. If you think that your voice has become rough as a singer, then it's better to have your vocal folds looked at prior to trying to do something like this because the straw phonation, if you had a nodule or a that constant contact, even though it's very gentle, could potentially make those lesions worse.

[00:39:17] Lynch-Reichert: Good to know, thank you for that caution. Dr. Halstead, it has been our pleasure to speak with you about the great work you and MUSC are doing to mediate COVID-19 issues related to the creative especially as they relate to the joy of music and We are most grateful for your passion and ingenuity, as well as the gracious musical contributions of Mr. Rob Taylor, Ms. Conant, and the Taylor Festival Choir, and exceedingly grateful for the innovative and informative work of Doctors Weaver and Spede, co-chairs of the Performing Arts Aerosol Study Coalition.

Again, we will put the links out there for those interested in learning more and seeing exactly how the aerosol study graphically shows how the COVID-19 can be transmitted. To our listeners, on behalf of the Medical University of South Carolina, and our Office of the Vice President for Research, we wish everyone a safe, joyful, peaceful, and musical end of 2020, and hope to join with you again via podcast or in person for our MUSC Science Cafe series and Science Never Sleeps. We will leave you now with more song from the Taylor Festival Choir.

Thank you all, and we'll see you in 2021.