The Semmelweis Effect and The Great Barrington Declaration

The story is often told in medical school about Ignaz Semmelweis, the Hungarian obstetrician who discovered that hand washing with chlorine reduced maternal mortality from puerperal fever. An intervention seemingly so simple and obvious but when first proposed in the 1840s, the experts of the day not only rejected it, but condemned Semmelweis as a heretic. The parallels between Semmelweis’s story and the Great Barrington Declaration (GBD) authors recall the adage that history may not repeat itself, but it sure rhymes.

In the 1840’s, Semmelweis was the equivalent of a modern-day Chief Resident (sans work hours limitations) on an obstetric ward at Vienna General Hospital. Physician-led wards had much higher puerperal fever rates than did the adjacent wards staffed by midwives.

Autopsies were common back then. Physicians, not midwives, attended autopsies and rotated frequently throughout the day between the autopsy and delivery rooms. A friend of Semmelweis cut his finger during an autopsy. He developed sepsis very similar to puerperal fever and died. Given the similarities between the way his friend died and death from puerperal fever, Semmelweis thought that there must be some pathogen transmitted by dead tissue causing sepsis. He noted the smell of death was on his hands after performing an autopsy and that this smell did not do away with conventional hand washing with soap and water. The odor could be eliminated with chlorine. Semmelweis then adopted a chorine-based hand washing regimen resulting in a marked decrease in puerperal fever on his ward.

Semmelweis spent the next 20 years trying to convince the obstetric community of the benefits of chlorinated water washing. He was ignored. Luminaries of his time such as Virchow, of node fame, chastised Semmelweis believing that puerperal fever was a manifestation of venous thrombosis caused by abnormal uterine contractions. It is said that Semmelweis went insane because his life-saving discovery was rejected by the academic community. He died in an asylum.

The problem of new ideas being rejected by experts is so pervasive it should have its own term, something like the Semmelweis Effect. The Semmelweis Effect originated in Vienna but about 100 years later in nearby Germany, history repeated itself. A German surgeon, Eric Muhe, developed a new technique for gall bladder removal in 1985 using telescopic instruments introduced into the abdomen through a series of small incisions - the first laparoscopic cholecystectomies. Muhe reported his first 100 cases to various German medical societies. Not only was his new approach to cholecystectomy rejected by his colleagues, but he was charged with murder in 1987 when one of his patients died of a complication unrelated to the laparoscopic approach procedure.

For many years, the French surgeon, Phillipe Mouret, was credited for inventing laparoscopic cholecystectomy a full two years after Muhe. Because Muhe was so thoroughly discredited by his colleagues for performing what the Germans at the time considered dangerous and irresponsible surgery, Muhe’s achievement went unrecognized for many years.

The Semmelweis Effect remains stubbornly common. The Effect was in play with PCR’s invention by Kary Mullis, discovery of the cholesterol receptor by Brown and Goldstein, with accepting that H. Pylori causes gastroduodenal ulcer disease (Barry Marshall), and identifying nutritional deficiencies as causing pellagra (Joseph Goldberger). The notion that tobacco smoking causes lung cancer was vigorously opposed by Sir Ronald Fisher, perhaps the most famous statistician, because of inconsistencies in the data supporting that hypothesis.¹

Despite the rich history of the dangers of rejecting new or alternate ideas about disease, the medical establishment has not learned its lesson. With COVID, the Semmelweis Effect was in full force. This time, it was the GBD authors who were the witches burned at the stake.

Jay Bhattacharya, who authored the declaration with Dr. Martin Kulldorff and Dr. Sunetra Gupta, is the face of the GBD and a modern day Semmelweis. ²Bhattacharya and his colleagues issued the Great Barrington Declaration on October 4, 2020, the pandemic was raging and the response to it was chaotic, calling for a reasoned approach to COVID.

The medical establishment should have known better. There were similarities between COVID and the AIDS epidemics. With AIDS, the medical establishment pursued the opposite approach than it did for COVID. With COVID, public health officials demanded isolation and lockdowns. The response to AIDS was very different: The medical establishment urged calm and the implementation of appropriate precautions, not isolation.

AIDS patients were frightful looking-they were severely cachectic and had skin lesions giving them the appearance of lepers. AIDS patients died painful and, early on, lonely deaths, locked away in hospital rooms that had restricted entry.

Early in the AIDS epidemic, CDC case officers realized that AIDS spread the same way as hepatitis. Because AIDS was not transmitted through the air, they knew it was safe to be in close proximity with the patients. All that was needed was the implementation of what we now know as universal precautions to avoid contact with blood or secretions. That AIDS patients did not need to be locked away was part of the message public health officials communicated. This was not easy given the public’s panic about AIDS in the 1980s. By the 1990’s, patients dying with AIDS were surrounded by loved ones.

An irony is why some of the same public health experts such as Dr. Anthony Fauci would reverse course during the COVID pandemic.

The basic approach that worked for AIDS should have been implemented for COVID. Understand its basic biology and then determine how to respond to the pandemic.

COVID is caused by the SARS CoV-2 virus, a coronavirus, the same family of viruses responsible for the common cold. What was known about disease caused by these viruses before the pandemic? From the 18th edition of Harrison’s Principles of Internal Medicine published in 2012 referring to the 2003 SARS :

“…The disease appeared to be somewhat milder in cases in the United States and was clearly less severe among children,” “…spread may occur by both large and small aerosols and perhaps by the fecal-oral route as well.” “…environmental sources, such as sewage or water, may also play a role in transmission.” “Some ill individuals (“superspreaders”) appeared to be hyper infectious and were capable of transmitting infection to 10-20 contacts…”

“…risk factors for severe disease include age>50 years and comorbidities such as cardiovascular diseases, diabetes, or hepatitis. Illness in pregnant women may be particularly severe, but SARS-CoV infection appears to be milder in children than in adults.”

One could copy these statements written about SARS in 2012 and apply them to the SARS-CoV-2 virus in 2024. The approach to COVID, proposed by the GBD, should have followed the same play book used by public health officials in the 1980s for AIDS. Take what is known about the virus, craft public policy from that knowledge and then educate the public about the disease in a way as to sooth their fears.

Instead of giving the GBD serious consideration, public health officials and other experts implemented the Semmelweis Effect. The GBD was characterized as ‘wishful thinking’ and ‘is based on a false premise.’ Dr. Fauci from the NIH called it "ridiculous", "total nonsense" and "very dangerous." Dr. Francis Collins, also from the NIH said it is “a fringe component of epidemiology. This is not mainstream science. It's dangerous. It fits into the political views of certain parts of our confused political establishment."

We now know that Dr. Bhattacharya and the other GBD authors were correct, and the experts were very wrong. The Semmelweis Effect. Going forward, experts should be careful before discrediting new ideas. The more passionate the experts are about countering something, the more skeptical the public will be about the experts.

The public watched as the Semmelweis effect played out during the COVID pandemic. They might naturally extend their learned skepticism of experts and begin to doubt those experts’ critiques of the MMR vaccine-autism relationship. After all, the MMR vaccine-autism hypothesis was promoted by experts in the pages of the prestigious journal Lancet that had the paper on its books for 12 years. Now experts are saying that relationship is false and vilify anyone who went along with their earlier claim that it was true. What is the public to believe?

A lesson from the Semmelweis effect is to not reject contrary ideas out of hand and rely on one’s authority as a proxy for scientific truth. Rather, experts should provide reasoned arguments for their position on any topic and explain the basis for their thinking in terms non-exerts can understand.

Dr. Livingston is a Professor of Surgery at UCLA and former Deputy Editor at JAMA.

1. Of course, there are also innumerable examples of people being ostracized for ideas that turned out to be meritless. The liberation procedure is a good recent example.

2. Hopefully without the bad ending of dying in an asylum.