Trial By Error: A Response to Call for “A New Paradigm” for Long Covid in Lancet Respiratory Medicine

By David Tuller, DrPH

Update, Feb 3rd:

After less than 24 hours, our letter was rejected by the journal. Here’s the message I received:

Dear Dr Tuller,

Thank you for your recent submission to The Lancet Respiratory Medicine. We have now had time to consider your manuscript and unfortunately, on this occasion, we have decided not to publish it because we have limited space in the journal and cannot give your paper priority over other letters we have in the pipeline.

Although this decision has not been a positive one, I thank you for your interest in the journal and hope it does not deter you from considering us again in the future.

Yours sincerely,

Dr. Emma Grainger
Editor-in-Chief, The Lancet Respiratory Medicine

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Last month, The Lancet Respiratory Medicine published a comment called “A new paradigm is needed to explain long COVID.” Not surprisingly, this “new paradigm” is the same old paradigm that has been applied to ME and CFS patients for decades. That paradigm, of course, has been debunked and discredited–even though many people seem not to have come to terms with that reality yet.

The journal has already rejected a couple of letters responding to the comment. I just submitted another, on behalf of myself and Sarah Tyson, a professor of rehabilitation in the Division of Nursing, Midwifery & Social Work at the University of Manchester. I have also posted it on a pre-print server, and am sharing it below.

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To the editor:

The authors of “A new paradigm is needed to explain Long COVID” suggest that Long Covid is largely a “functional” disorder attributable to pandemic-related stress, anxiety, depression and a host of additional factors unrelated to pathophysiological processes.[1] It goes without saying that psychological states and social and environmental conditions can have a major impact on health status and exacerbate underlying health conditions. Moreover, mental health disorders are often associated with somatic complaints like fatigue and pain. But that’s very different from arguing—without legitimate or valid evidence–that millions of people with devastating and prolonged disabilities are experiencing what the authors call “functional” complaints triggered mainly by mood disorders. Rather than these disorders being the cause of the global wave of life-altering symptoms, they are more plausibly viewed as a frequent consequence of the experience of having a poorly understood and often belittled illness.  

Long Covid is a heterogeneous phenomenon involving multiple symptoms produced through a range of physiological pathways, as has become evident from the emerging research. [2] It would be unwarranted to expect a single unifying explanation to account for long Covid’s many manifestations. However, in supporting their position, the authors cite the lack of “an all-encompassing pathophysiological mechanism.” This is a straw-person argument. No reasonable investigators have proposed the existence of “an all-encompassing, pathophysiological mechanism” that is responsible for generating the entire spectrum of long Covid symptoms.

The authors dismiss efforts to seek pathophysiological explanations for patients’ physical symptoms with the tired charge that this approach represents “dualistic” thinking. As an alternative, they are proposing grand theories regarding “functional” etiologies and apparently expecting others to embrace these unproven speculations—an expectation that suggests a certain level of arrogance. It is simply too soon for investigators to have obtained authoritative answers to a phenomenon as complex and varied as the long-term impacts of coronavirus infection and acute COVID-19. Perhaps if the field of post-viral illness had not been neglected for decades, and patients with ME/CFS and related conditions had not been ignored and mistreated, we would understand a lot more now about the medical challenges confronting long Covid patients.

David Tuller
Senior Fellow in Public Health and Journalism
Center for Global Public Health
School of Public Health
University of California, Berkeley Sarah Tyson

Sarah Tyson
Professor of Rehabilitation
Division of Nursing, Midwifery & Social Work
School of Health Sciences
University of Manchester

[1] Saunders C, Sperling S, Bendstrup E. A new paradigm is needed to explain long COVID. Lancet Respiratory Medicine 2023;11; 2:e12. DOI: 10.1016/S2213-2600(22)00501-X

[2] Davis HE, McCorkell L, Vogel JM, Topol EJ. Long COVID: major findings, mechanisms and recommendations. Nature Reviews Microbiology 2023; Jan 13:1-14. DOI: 10.1038/s41579-022-00846-2