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| EDITORIAL |
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| Year : 2022 | Volume
: 15
| Issue : 4 | Page : 453-454 |
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Paradigm shifts in public health: Lessons from the Covid-19 pandemic
Amitav Banerjee
Department of Community Medicine, Dr DY Patil Medical College, Hospital and Research Centre, Dr. DY Patil Vidyapeeth, Pune, Maharashtra, India
| Date of Submission | 17-May-2022 |
| Date of Decision | 20-May-2022 |
| Date of Acceptance | 25-May-2022 |
| Date of Web Publication | 20-Jun-2022 |
Correspondence Address:
Amitav Banerjee
Department of Community Medicine, Dr DY Patil Medical College, Hospital and Research Centre, Dr. DY Patil Vidyapeeth, Pune, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/mjdrdypu.mjdrdypu_418_22
How to cite this article:
Banerjee A. Paradigm shifts in public health: Lessons from the Covid-19 pandemic. Med J DY Patil Vidyapeeth 2022;15:453-4 |
Unlike clinical medicine, where paradigm shifts in the management of individual diseases cause less disruption, for better or worse, paradigm shifts in public health can have far-reaching and widespread impacts on populations.
To illustrate, the paradigm shift in the management of peptic ulcer disease occurred around the early 1980s with the proposition that Helicobacter pylori  a majority of stomach ulcers.[1] While this considerably eased the management of peptic ulcer disease as a large number of patients could be cured with antibiotics without the need for surgery or prolonged medications, this impact did not extend beyond patients with peptic ulcer syndrome. Had there been any error of judgment in this proposition, the adverse impact, too, would have been limited in one dimension.
On the other hand, paradigm shifts in public health practice, if driven by errors of judgment, can be disastrously extensive. The devastations caused by the measures implemented by most countries in the present pandemic, the so-called “deaths by despair” confirm this.[2] An analysis of deviations from public health principles in this pandemic and what prompted these shifts is important if we are not to repeat the mistakes which caused so much misery.
What were these paradigm shifts? These were, lowering the bars for declaring a pandemic; classification of cases and deaths attributed to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); quarantining the young and healthy; downplaying the role of naturally acquired immunity; and chasing and subsequently trying to eradicate a virus with one of the lowest lethality among all communicable and non-communicable diseases of humankind.
The World Health Organization (WHO) lowered the criteria to make this a pandemic.[2] To meet the pandemic status, a disease must have a high mortality rate among the vast majority of people, particularly the young and healthy. Coronavirus Disease 2019 (Covid-19), with a survival rate of 99.98% in the young and healthy, was way off the mark. The very foundation, i.e., the case definition, on which the pandemic narrative unfolded was also weak. Each positive laboratory test based on the dubious reverse transcription-polymerase chain reaction (RT-PCR) was reported as a Covid-19 case, irrespective of clinical signs and symptoms.[3],[4] This case definition took us back hundreds of years in infectious disease epidemiology when it was realized that it is important to differentiate between “infection” and “disease.” Living beings, including humans, harbor multitudes of microbes within them, many with the potential to cause disease but never do under normal circumstances. Many healthy people carry meningococci or pneumococci in their upper respiratory tracts, but isolating these organisms from throat swabs in asymptomatic people is not sufficient to identify them as cases of meningitis or pneumococcal pneumonia. This nuance was overlooked in the present pandemic, inflating the case counts and resulting in chaos. Covid-19 is a severe disease that occurs in less than 10% of the people who are detected positive with RT-PCR.[5] The misclassification of cases caused by the paradigm shift in case definition drove the figures high, giving an illusion of existential threat.
Another violation of epidemiological and public health principles was the certification of the cause of death. Every death in which there was an RT-PCR positive report, even if coincidental, was certified as a Covid death. The method of death certification violated all international medical guidelines.[3] This absurdity is brought into sharp focus with reports of gun-shot deaths being classified as Covid-19 deaths on the victims testing positive.[6]
With such a tragicomedy of errors, the recent claim by the World Health Organization (WHO) of underreporting of Covid-19 deaths in India based on sterile mathematical models insulated from ground realities is unfounded and shallow.[7]
Traditionally, the sick were quarantined and isolated to check disease spread of communicable diseases, never the healthy. The paradigm shift in this pandemic precipitated by authoritarian China was mass quarantines and lockdowns, including the young and healthy who were at minimal risk of adverse outcomes from the infection. Rightly, the WHO representative in Beijing stated that such draconian measures were unprecedented in public health history and not endorsed by the WHO.[8],[9] Subsequently, most countries in the world, with few exceptions like Sweden, Japan, and Belarus, outdid China in implementing these harsh measures. While these unprecedented measures failed to check transmission, as evidenced by the high seroprevalence of Immunoglobulin G (IgG) antibodies, particularly in densely populated Asian and African countries, they led to severe collateral harm. Livelihoods and lives were destroyed. Draconian measures cause deaths in the developing world to prolong lives in the developed world.[10]
We have known for a long that recovery from viral infections confers robust and long-lasting immunity. The proportion of people who recover builds up in the course of the pandemic and, at a critical point, acts as brakes, halting the pandemic. This is the natural history of pandemics. Never in public health history has mass vaccination in populations with a high proportion of individuals with natural immunity ever been implemented. Strangely, during this pandemic, the most haloed scientific institutions and government guidelines downplayed the role of natural immunity and strongly recommended vaccination for all, including those who had recovered from natural infection. Studies have established that natural immunity is 13 to 26 times more robust than vaccine-induced immunity.[11]
Another resource-intensive, costly, and futile activity during the pandemic was the emphasis on testing, contact tracing, and isolation throughout the course of the pandemic. These measures are important in the early phase of the pandemic before community transmission has set in, after which they are futile.
Two years into the pandemic, the drastic measures and mass vaccination of populations had a very modest impact or advantage over the natural history of the pandemic, which unfolded like past pandemics with peaks and troughs before vanishing into the blue. [12],[13],[14]
It is time for introspection, “chintan,” and soul-searching by all honest scientists.
| References | |  |
| 1. | Basset C, Holton J, Vaira D. Helicobacter: A paradigm shift in peptic ulcer disease and more? Sci Prog 2002;85:13-31.  |
| 2. | Blaylock RL. COVID UPDATE: What is the truth? Surg Neurol Int 2022;13:167. |
| 3. | Reiss K, Bhakdi S. How Dangerous is the New “Killer” Virus? In: CORONA - False Alarm Facts and Figures. London, Chelsea Green Publishing; 2020. p. 15-39. |
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| 5. | Day M. Covid-19: Four fifths of cases are asymptomatic, China figures indicate. BMJ 2020;369:m1375. |
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| 9. | Caduff C. What Went Wrong? Corona and the world after the full stop. Med Anthropol Q 2020;34:467-87. |
| 10. | Broadbent A, Walker D, Chalkidou K, Sullivan R, Glassman A. Lockdown is not egalitarian: The costs fall on the global poor. Lancet 2020;396:10243:21-2. |
| 11. | Gazit S, Shlezinger R, Perez G, Lotan R, Peretz A, Ben-Tov A, et al. Comparing SARS-CoV-2 natural immunity to vaccine-induced immunity: Reinfections versus breakthrough infections. medRxiv 2021.08.24.21262415. doi: 10.1101/2021.08.24.21262415. |
| 12. | Banerjee A. Chasing the virus: Not only difficult but impossible. Are we going to hit a dead end?. Med J DY Patil Vidyapeeth 2020;13:425-6. |
| 13. | Banerjee A. COVID-19: Did the dog bark?. Med J DY Patil Vidyapeeth 2022;15:143-5. [Full text] |
| 14. | Banerjee A. Covid-19 mass vaccination – How much impact at population level?. Med J DY Patil Vidyapeeth 2022;15:293-8. [Full text] |
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