Intended for healthcare professionals

Rapid response to:


Calibrated response to emerging infections

BMJ 2009; 339 doi: (Published 03 September 2009) Cite this as: BMJ 2009;339:b3471

Rapid Response:

Worst-case scenarios: the public health response to Covid-19

Dear Editor,

It has been nearly 12 years since Peter Doshi said, as a graduate student, that public health authorities should consider more than worst-case scenarios in responding to emerging infections. (Doshi, BMJ 2009;339:b3471) They should have listened…. By consistently assuming the worst in responding to the Covid-19 pandemic authorities have arguably done a great deal more harm than good: they declared lockdowns in the absence of empirical evidence for their safety and effectiveness; they instituted mass screening of healthy and asymptomatic individuals, using tests that yielded large numbers of false positives; they assumed that natural immunity from infection contributes nothing to population/herd immunity; they assumed that 80% to 90% of the population must be vaccinated to achieve population immunity…..The most recent example of assuming the worst is guidance from the US Centers for Disease Control and Prevention that people should continue to wear masks outdoors, even as the number of US Covid-19 cases plummets. CDC guidance was based on their estimate that as much as 10 percent of Covid transmission occurs out of doors. The estimate came from a single review article, but Dr. Nooshin Razani, one of the article’s authors, stated that the actual share of outdoor transmission was “probably substantially less than 1 percent” based on the studies reviewed. David Leonhardt, who reported this in the New York Times on May 27, cites this as an example of extreme caution, and he asserts that “…more than once during this pandemic, CDC officials have acted as if extreme caution has no downsides.”…..Why have authorities gravitated to the worst-case scenarios questioned by Peter Doshi?

Public health officials are scientists and humanitarians, but they are also bureaucrats, subject to personal limitations and conflicts of interest. Our bafflement about their policies and decisions can be resolved with a little introspection: FEAR is surely one of the elements driving public health decision making—fear of the virus itself, and fear of being held responsible for poor decisions. In the face of bad outcomes, people in authority are more likely to be criticized for doing too little than doing too much, so they tend to do too much……IGNORANCE is a close ally of fear. Back in January 2020 we knew very little about Covid-19, and even today our knowledge is limited. Uncertainty reinforces the fear that goes with decision-making…..ARROGANCE is a by-product of authority and has to be considered in trying to understand confident official pronouncements in the face of uncertainty.….COMMERCIAL INTERESTS cannot be ignored. US public health agencies such as the FDA, the CDC, and the NIH have close working relationships with manufacturers of drugs and vaccines who are also the source of substantial financial subsidies…..It may seem redundant to add PERSONAL AMBITION to the foregoing list, but the desire for power and prestige is not rare and could affect the decisions of the most humane officials……There is nothing new in the foregoing list, and I offer it only as a reminder—to public health authorities, to newspeople, to health professionals, and to the lay public who must decide how to respond to official recommendations.

It has been asserted that Covid-19 escaped from a laboratory, that the laboratory had been engaged in “gain-of function research”, and that some of the money to fund the research came from the NIH/NIAID in the US. We may never know the origin of Covid-19, but one cannot help wondering if the knowledge of these possibilities has affected the response of public health officials to the Covid-19 pandemic.

Public health authorities habitually assume worst-case scenarios, just to be on the safe side. This is unwise…. Aldo Leopold was a forester, ecologist, conservationist and philosopher from my home State of Wisconsin. He had a profound impact on the environmental movement, and in an essay titled ‘Thinking like a mountain’ he said this: “We all strive for safety, prosperity, comfort, long life, and dullness…but too much safety seems to lead only to danger in the long run.” (Sand County Almanac, 1949)…..Words for all of us to conjure with.


Competing interests: No competing interests

02 June 2021
Allan S. Cunningham
Retired pediatrician
Cooperstown NY 13326 USA <