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Building a Multisystemic Understanding Of Analysis Building a multisystemic understanding BMJ Glob Health: first published as 10.1136/bmjgh-2021-006794 on 22 July 2021. Downloaded from of societal resilience to the COVID-19 pandemic 1 1 2 3 Didier Wernli , Mia Clausin, Nino Antulov- Fantulin, John Berezowski, 4 5 6 7 Nikola Biller, Karl Blanchet , Lucas Böttcher, Claudine Burton- Jeangros, Gérard Escher,8 Antoine Flahault,9 Keiji Fukuda,10 Dirk Helbing,2 Philip D Jaffé,11 Peter Søgaard Jørgensen,12,13 Yuliya Kaspiarovich,1 Jaya Krishnakumar,14 15 16 1 1,17 Roderick John Lawrence, Kelley Lee , Anaïs Léger, Nicolas Levrat, 18 1 18 19,20 Romain Martischang, Chantal M Morel , Didier Pittet, Maxime Stauffer, Fabrizio Tediosi,21,22 Flore Vanackere,1 Jean- Dominique Vassalli,23,24 Gaélane Wolff,25 Oran Young26 To cite: Wernli D, Clausin M, ABSTRACT Summary box Antulov- Fantulin N, et al. The current global systemic crisis reveals how globalised Building a multisystemic societies are unprepared to face a pandemic. Beyond ► The COVID-19 pandemic has tested resilience in understanding of societal the dramatic loss of human life, the COVID-19 pandemic resilience to the COVID-19 health but also social, economic, environmental and has triggered widespread disturbances in health, social, pandemic. BMJ Global Health governance systems across the world. economic, environmental and governance systems in 2021;6:e006794. doi:10.1136/ ► Progress has been made in recent years to define many countries across the world. Resilience describes bmjgh-2021-006794 and assess health system resilience, but broader the capacities of natural and human systems to prevent, societal resilience to emerging infectious diseases react to and recover from shocks. Societal resilience is not well defined. Received 2 July 2021 to the current COVID-19 pandemic relates to the ability ► Societal resilience to the current COVID-19 pandem- Accepted 7 July 2021 of societies in maintaining their core functions while ic relates to the ability of societies to maintain their minimising the impact of the pandemic and other core functions while minimising the health impact of societal effects. Drawing on the emerging evidence about the pandemic and other societal effects. resilience in health, social, economic, environmental and ► Developing evidence about resilience in different governance systems, this paper delineates a multisystemic systems will serve as the foundation for an integrat- understanding of societal resilience to COVID-19. Such an http://gh.bmj.com/ ed approach to build societal resilience to COVID-19 understanding provides the foundation for an integrated and future pandemics. approach to build societal resilience to current and future pandemics. pandemic preparedness did not predict countries’ capacities to address the COVID-19 on July 22, 2021 by guest. Protected copyright. RESILIENCE OF WHOM TO WHAT? pandemic.3 The ecological, economic and social The COVID-19 pandemic has tested the complexity of global societal challenges is resilience of societies to a systemic crisis that the linchpin of the COVID-19 pandemic.1 impacts the life of billions of people world- High levels of connectivity and coupling in wide. While there is a growing interest in a globalised world created pathways for the health resilience to the COVID-19 pandemic, initial manifestations of the crisis to propa- the broader understanding of societal resil- © Author(s) (or their gate and amplify.2 The COVID-19 pandemic ience is not well defined. A multidimen- employer(s)) 2021. Re- use and its associated responses have interfered sional definition of resilience is useful when permitted under CC BY-NC. No commercial re- use. See rights broadly with human activities and have gener- addressing issues that are closely inter- 4 and permissions. Published by ated wide- ranging systemic effects in health, twined. In line with recent developments BMJ. economic, social, environmental and govern- in the study of resilience,5 this paper aims For numbered affiliations see ance systems worldwide. Not all societies have to develop a multisystemic understanding end of article. been affected in the same way. Disruptions of societal resilience to COVID-19. We Correspondence to were particularly severe in countries that were define societal resilience to the COVID-19 Dr Didier Wernli; unable to control widespread community pandemic as the ability of societies to contain didier. wernli@ unige. ch transmission. Prior assessment of countries’ the pandemic while maintaining their core Wernli D, et al. BMJ Global Health 2021;6:e006794. doi:10.1136/bmjgh-2021-006794 1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2021-006794 on 22 July 2021. Downloaded from Figure 1 Interconnected societal systems and their different goals in addressing the COVID-19 pandemic. governance functions and minimising any undesirable RESILIENCE IN DIFFERENT SYSTEMS systemic effects. This definition encompasses the capac- Health resilience encompasses capacities at several scales ities of societies to (1) prepare, prevent and protect of social organisation to promote, restore and maintain before disruption; (2) mitigate, absorb and adapt during health when confronted with a shock.8 A first challenge disruptions; and (3) restore, recover and transform after of SARS- CoV-2 and its various variants relates to their disruption.6 high transmissibility. Second, the absence of immunity The world consists of highly composite systems to SARS- CoV-2 in the population makes a proportion whose interacting parts give rise to a behaviour that of the population, the size of which is influenced by is more than the sum of the parts. From single organ- different risk factors, susceptible to severe infections and http://gh.bmj.com/ 9 isms to ecosystems, communities and whole societies, deaths. Health resilience to the COVID-19 pandemic these organised wholes are called ‘complex adaptive is thus broadly referred to the capacities to prevent or systems’.7 Contemporary societies are usually organised reduce both transmission and mortality of SARS- CoV-2. into several and sometimes overlapping complex adap- Preventing transmission primarily involves actions to tive systems, based on societal sectors such as health, reduce exposure to SARS-CoV -2. At the individual and community levels, this means making informed deci- on July 22, 2021 by guest. Protected copyright. the economy and the environment. Societal resilience sions that protect themselves and others (eg, physical thereby relates to the effectiveness of the response distancing, wearing a mask and reducing the number across different sectoral systems, which have distinct of close contact interaction with others). Furthermore, rules, expertise and institutions. Another element is the resilience derives from the capacity of public health resilience of governance systems to ensure an effective, authorities to prevent and slow down transmission by legitimate and accountable response. From a multisys- implementing contact tracing, case isolation and quar- temic perspective, a striking challenge of the COVID-19 antine. Experiences in several countries across the world pandemic is managing trade-offs between systems that have shown that rapid actions are largely successful in have different goals (figure 1). In this paper, we seek to preventing community transmission.10 When they were define resilience in the health, economic, social, envi- not, community transmission leads to a surge of patients ronmental and governance systems. For each system, we in healthcare systems. Healthcare resilience to the provide examples of how resilience has been expressed COVID-19 pandemic relies primarily on how hospitals at different scales of social organisation. A multisystemic cope with a surge of patients and, when capacities are approach can help understand how societies as a whole exceeded, adapt through reorganisation and an appro- are affected by and react to systemic crises. This in turn priate and timely allocation of resources.11 Finally, the provides the basis for the development of integrated COVID-19 pandemic also underlines the contribution approach to foster resilience to pandemics. of other stakeholders to resilience. Vaccines developed 2 Wernli D, et al. BMJ Global Health 2021;6:e006794. doi:10.1136/bmjgh-2021-006794 BMJ Global Health by the pharmaceutical industry increase resilience by which often have the most market power, were less prone BMJ Glob Health: first published as 10.1136/bmjgh-2021-006794 on 22 July 2021. Downloaded from reducing transmission, morbidity and mortality.12 Finally, to liquidity problems than small-sized and medium- sized a critical issue underpinning global health resilience businesses.28 29 As an important risk for companies was is improved coordinated country efforts to address to become insolvent, resilience relied on governmental the short- term and long- term health needs of all while support such as loans, subsidies and deferrals of taxes.30 limiting further disruptions linked to COVID-19. To avoid a sharp rise in unemployment, financial assis- Social resilience is the capacity of societies to maintain tance to businesses was further increased in the form of their core social functions and reduce the social impact benefits for employees or partial unemployment compen- of a shock. It involves different scales of social organi- sation schemes. Macroeconomic resilience is concerned sation including individuals, families, communities and with how different sectors and countries were able to societies.13
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