The researchers examined two of the most prominent post-hoc evaluations of national Covid-19 responses, published between 2022 and 2024 by two leading medical journals: The Lancet and The BMJ. The Lancet Commission on lessons for the future from the Covid-19 pandemic, released in 2022, provided a comprehensive analysis of government responses and recommendations for future pandemics. The BMJ published three separate series—one informing the United Kingdom’s Covid-19 Inquiry, one on accountability for Canada’s response, and one on lessons for future health protection and preparedness in the United States—comprising 25 analyses, opinions, and editorials. These journals played a critical role in shaping global policymaking during the pandemic, publishing some of the most important studies on Covid-19 and evaluating the effectiveness of non-pharmaceutical interventions such as mask mandates and lockdowns.

What the team found was striking. Across all 25 articles in the three BMJ series, references to the harms of public health interventions accounted for less than 1 percent of the total content. In the Canadian series, only one article out of seven mentioned harm at all, and just two sentences—38 words out of 13,033 total words, or 0.29 percent of the text—addressed the issue. In the US series, four sentences in the series editorial indirectly described harms, representing 101 words out of 16,299 total words, or 0.62 percent. The UK series fared marginally better, with nine sentences totaling 207 words out of 25,003 words, or 0.83 percent. None of the BMJ articles incorporated any form of cost-benefit analysis. The Lancet Commission mentioned harms in a few sections—briefly noting effects on marginalized individuals, the poor, displaced children, and refugees—but did not discuss them systematically, made only a minor and cursory reference to policy trade-offs, and failed to incorporate them into its recommendations.

The authors argue that this omission is both surprising and consequential. The field of harm-benefit analysis is well established in public health, and the notion that interventions involve trade-offs between benefits and harms should be uncontroversial. Cost-benefit analysis is routinely employed in other fields—environmental, consumer, and financial regulation—areas that also impact the well-being of large populations. Yet public health scholars have largely avoided applying a benefit-harm framework to Covid, partly for moral reasons: such analysis often involves assigning a monetary value to life. The authors contend that this natural reluctance, while understandable, impedes sound policy analysis in a world of limited resources, and that acknowledging that interventions can cause harms—even if inadvertent—is essential for restoring trust in public health authorities.

The harms of pandemic interventions were real and increasingly documented. Lockdowns disadvantaged low-income populations and young people. Social isolation measures harmed those struggling with addiction and mental health disorders. School closures hurt children and their families, with evidence from the United States showing substantial learning losses associated with remote and hybrid schooling, with larger declines in districts serving more Black students and effects that may be long lasting. A comprehensive framework has recently been published identifying the range of harms of non-pharmaceutical interventions and reviewing their magnitude. Another framework focused on health inequalities shows that several interventions not only perpetuated and exacerbated pre-existing inequities but also created new ones. Policies designed to improve public health can disproportionately harm disadvantaged populations, contributing to unequal socio-economic outcomes.

Ignoring these harms and trade-offs, the authors argue, erodes public trust in health authorities. The history of epidemics teaches that overly paternalistic interventions can lead to conflict and mistrust. As historian of epidemics David Jones noted, epidemic responses such as quarantine or compulsory vaccination generally involve people with power and privilege imposing interventions on people without power or privilege—a dynamic that fuels social conflict. Trust is critical in public health because it facilitates consent, a necessary condition for widespread adoption of measures such as immunization programs. Lack of trust increases non-compliance and vocal opposition to health authorities. The erosion of trust may already be visible: in the United States and parts of Canada, routine childhood vaccination requirements are increasingly challenged, exemptions are rising, and outbreaks of preventable diseases such as measles have re-emerged.

The global dimension of this blind spot is particularly severe. Data from the World Bank and UN agencies showed that over 400 million people fell below their national poverty line in 2022, with low-income countries experiencing a disproportionate share of the drop. UNICEF estimates a 13 percent global increase in learning poverty—the share of children who cannot read a simple text with comprehension by age 10—disproportionately higher in low- and middle-income countries, essentially erasing all educational gains since 2000 and estimated to cost the current generation of students $21 trillion in lost earning potential. Millions of children missed essential vaccines, with nearly four million more unvaccinated children than in 2019. Country-level evidence illustrates the severity: in Uganda, lockdowns were associated with disruptions to family stability, housing, schooling, food security, and increased gender-based violence and child labour. In Angola, where 77 percent of the population worked in the informal economy, unemployment in September 2020 was 34 percent higher than in 2019, and a survey of informal-sector operators in Luanda found that 95.8 percent reported significant or marginal reductions in income. In India, the March 2020 nationwide lockdown abruptly disrupted migrant workers’ livelihoods, prompting large numbers to return to their home states.

To explain why these assessments failed, the authors draw on the disproportionate policy response literature from political science, which holds that governments can either over-react or under-react to situations requiring a policy response. Over-reaction occurs when a policy’s net cost exceeds its benefit—when the scale, stringency, or breadth of intervention is disproportionate to the problem. Under-reaction occurs when a policy’s net benefit is lower than the relevant status-quo counterfactual—when action is weaker or narrower than warranted by the risk. The BMJ and Lancet inquiries focused almost entirely on the under-reaction perspective, highlighting failures to act while largely ignoring the possibility of over-reaction. This narrow framing, the authors argue, prevents a thorough investigation of trade-offs and leaves policymakers with a flawed toolkit for future emergencies.

Recent scholarship offers explanations for why over-reaction may have occurred. National committees advising governments were dominated by public health officials who lacked the expertise to evaluate the costs of non-pharmaceutical interventions and had little inclination to do so. As Francis Collins, a member of the White House Coronavirus Task Force, commented, decision-makers attached infinite value to stopping the disease and saving a life, and zero value to whether measures actually disrupted people’s lives, ruined the economy, and kept children out of school. The media focused too heavily on disease spread and deaths rather than the costs of prevention measures. Academics willing to investigate trade-offs often found themselves subjected to invective, character attacks, and reputational damage. Political science literature also identifies conditions favoring major policy change: high issue salience, especially during crises when the public feels anxious and vulnerable, and a low number of veto players—during the pandemic, major decisions were taken almost exclusively by executive branches insulated from meaningful oversight by other government bodies.

The authors conclude that accountability inquiries must assess the harms as well as the benefits of public health interventions and weigh them against each other—something that, so far, has not been done. The need to address trade-offs should be made explicit in the terms of reference of any inquiry, and invitees to hearings should reflect a broad range of views, placing pressure on committee members to consider the appropriate balance in their recommendations. Diversity of thought, free from ideological bias, is key to assessing the adequacy of government responses. Low-income countries, which often have younger populations at lower risk of serious harm from Covid-19 and lack necessities like clean water and food, may benefit from less restrictive approaches, and the most appropriate national policies are conditional on national demographic, social, and economic conditions. To improve public health outcomes, prevent the recurrence of policy mistakes, and restore trust in public health authorities, the authors argue that future pandemic preparedness must begin by acknowledging that interventions involve trade-offs—and by building the systematic evaluation of those trade-offs into decision-making from the start.

Subject of Research: Public Health Policy

Article Title: Incomplete Assessments: Including Harms and Trade-offs in Assessing Policy Approaches to Covid-19

Article References: Bavli, I., Sutton, B., Bardosh, K., & Galea, S. (2026). Incomplete Assessments: Including Harms and Trade-offs in Assessing Policy Approaches to Covid-19. SSM – Population Health, Article 101983. https://doi.org/10.1016/j.ssmph.2026.101983

Image Credits: AI Generated

DOI: 10.1016/j.ssmph.2026.101983

Keywords: Covid-19, public health, policy trade-offs, harm-benefit analysis, lockdowns, school closures, The Lancet, The BMJ, public trust, health inequities, low-income countries, disproportionate policy response