Building societal resilience to COVID-19 and future pandemics: a synthesis of the literature and a governance framework for action

Abstract

The current COVID-19 pandemic potentially threatens the foundation of societies worldwide. Con-temporary globalisation has brought many benefits but has also increased the risk that hazards arising in one part of the global system will more readily spread to other parts. Societal resilience to COVID-19 refers to the effectiveness of the public health response while mitigating other undesirable effects. Resilience thinking provides a framework to proactively integrate insights from different disciplines, to orchestrate a more nimble and effective response to COVID-19, and ultimately to alter trajectories in ways that mitigate the risk of future global health crises. The paper begins by taking stock of the current pandemic and the nature of the responses so far. Because the pandemic has impacted all of society, the paper then identifies enablers and obstacles to resilience in health, social, economic, and environmental systems. Finally, the paper provides some lessons learnt and recommendations to nurture and build a more resilient and sustainable society emerging from the COVID-19 pandemic. It argues that different forms of resilience for prevention, reaction, and recovery need to be built into how societies as a whole are organized and governed.

Full text

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Building societal resilience to COVID-19 and
future pandemics: a synthesis of the literature
and a governance framework for action
Preprint version 1.0 – 08.01.2021
Authors (alphabetical order): Nino Antulov-Fantulin1, Nikola Biller-Andorno2, Lucas Böttcher3, John
Berezowski4, Claudine Burton-Jeangros5, Karl Blanchet6, Mia Clausin7, Gérard Escher8, Antoine
Flahault9, Keiji Fukuda10, Dirk Helbing11, Philip D. Jaffé12, Peter Jørgensen13, Yuliya Kaspiarovich14, Jaya
Krishnakumar15, Roderick Lawrence16, Kelley Lee17, Anaïs Léger18, Nicolas Levrat19, Romain
Martischang20, Chantal Morel21, Didier Pittet22, Maxime Stauffer23, Fabrizio Tediosi24, Flore
Vanackere25, Jean-Dominique Vassalli26, Didier Wernli27, Gaélane Wolff28, Oran Young29
Affiliations: 1 Computational social science, ETH Zurich, Zurich, Switzerland, 2 Institute of Biomedical
Ethics and History of Medicine, University of Zurich, Zurich, Switzerland, 3 Computational Medicine,
UCLA, United States of America 4 Vetsuisse Faculty, Veterinary Public Health Institute, University of
Bern, Bern, Switzerland, 5 Department of sociology, University of Geneva, Switzerland. 6 Geneva
Centre of Humanitarian Studies, Faculty of Medicine, University of Geneva and Graduate Institute of
International and Development Studies, Geneva, Switzerland, 7 Geneva Transformative Governance
Lab, Global Studies Institute, University of Geneva, Geneva, Switzerland, 8 Swiss Federal Institute of
Technology Lausanne, Lausanne Switzerland, 9 Institute of Global Health, Faculty of Medicine,
University of Geneva, Geneva, Switzerland, 10 School of Public Health, Li Ka Shing Faculty of Medicine,
University of Hong Kong, Hong Kong Special Administrative Region, China, 11 Computational Social
Science, ETH Zurich, Zurich, Switzerland, 12 Interfaculty Center for Children's Rights Studies, University
of Geneva, Switzerland, 13 Global Economic Dynamics and the Biosphere, The Royal Swedish Academy
of Sciences, Stockholm, Sweden; Stockholm Resilience Centre, Stockholm University, Sweden, 14
Geneva Transformative Governance Lab, Global Studies Institute, University of Geneva, Geneva
Switzerland, 15 Institute of Economics and Econometrics, Geneva School of Economics and
Management, University of Geneva, Geneva, Switzerland, 16 Geneva School of Social Sciences (G3S),
University of Geneva, Geneva, Switzerland, 17 Faculty of Health Sciences, Simon Fraser University,
Burnaby, BC, Canada, 18 Geneva Transformative Governance Lab, Global Studies Institute, University
of Geneva, Switzerland, 19 Geneva Transformative Governance Lab, Global Studies Institute, University
of Geneva, Switzerland; Faculty of Law, University of Geneva, Geneva Switzerland, 20 Infection Control
Programme, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland, 21 Geneva
Transformative Governance Lab, Global Studies Institute, University of Geneva, Geneva Switzerland,
22 Infection Control Programme, University of Geneva Hospitals and Faculty of Medicine, Geneva,
Switzerland, 23 Geneva Science Policy Interface, University of Geneva, Geneva, Switzerland, 24
Household Economics & Health Systems Research Unit, Swiss Tropical and Public Health Institute,
Basel, Switzerland, 25 Geneva Transformative Governance Lab, Global Studies Institute, University of

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Geneva, Geneva, Switzerland, 26 Faculty of Medicine, University of Geneva, Switzerland; International
Institute for the Rights of the Child, Sion, Switzerland, 27 Geneva Transformative Governance Lab,
Global Studies Institute, University of Geneva, Geneva, Switzerland, 28 Global Studies Institute,
University of Geneva, Geneva, Switzerland, 29 Bren School of Environmental Science and Management,
University of California at Santa Barbara, Santa Barbara, California, USA.
Corresponding author: Didier Wernli (didier.wernli@unige.ch), Geneva Transformative Governance
Lab, Global Studies Institute, University of Geneva, 10 Rue des Vieux Grenadiers, 1205 Geneva, Swit-
zerland
Contribution: Didier Wernli (DW) did the background research and developed the successive drafts of
the paper. Lucas Böttcher and Nino Antulov-Fantulin developed the content and figure of box 1 in-
cluding figure 3. Mia Clausin designed figures 1, 2, 4, 6, 8, 10, and 11. Box 2, figures 5, 7 and 9, and all
tables were designed by DW. All co-authors contributed content and comments to the paper. The
authors of this paper appear in alphabetical order.
Abstract: The current COVID-19 pandemic potentially threatens the foundation of societies world-
wide. Contemporary globalisation has brought many benefits but has also increased the risk that haz-
ards arising in one part of the global system will more readily spread to other parts. Societal resilience
to COVID-19 refers to the effectiveness of the public health response while mitigating other undesir-
able effects. Resilience thinking provides a framework to proactively integrate insights from different
disciplines, to orchestrate a more nimble and effective response to COVID-19, and ultimately to alter
trajectories in ways that mitigate the risk of future global health crises. The paper begins by taking
stock of the current pandemic and the nature of the responses so far. Because the pandemic has im-
pacted all of society, the paper then identifies enablers and obstacles to resilience in health, social,
economic, and environmental systems. Finally, the paper provides some lessons learnt and recom-
mendations to nurture and build a more resilient and sustainable society emerging from the COVID-
19 pandemic. It argues that different forms of resilience for prevention, reaction, and recovery need
to be built into how societies as a whole are organized and governed.
Funding: The development of this paper was partly funded through a grant from the Geneva Science
Policy Interface (https://gspi.ch/). The paper has been written within the scope of the COVID-19 sys-
temic project (Grant 31CA30_196396, https://data.snf.ch/covid-19/snsf/196396) which is funded by
the Swiss National Science Foundation.
Keywords: COVID-19, pandemic, resilience, governance, sustainability, complexity, network, systemic
risk, systemic crisis, capacities, adaptation, transformation.
Wordcount: 18’468 words including tables.

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Contents
1 Introduction .................................................................................................................................... 4
2 Origin of and response to the pandemic through a complexity lens ............................................. 5
2.1 Context, drivers, and vulnerabilities ....................................................................................... 5
2.2 The government response to the COVID-19 pandemic .......................................................... 7
2.3 Ongoing challenges to effective public health responses ...................................................... 9
Box 1 – Challenges in epidemic modelling & forecasting of COVID-19 ............................................ 11
3 Systemic effects and societal resilience ........................................................................................ 12
Box 2 – Resilience and complex systems: What are we talking about? ........................................... 14
3.1 Health .................................................................................................................................... 17
3.2 Economic ............................................................................................................................... 20
3.3 Social ..................................................................................................................................... 22
3.4 Environmental ....................................................................................................................... 24
4 Governing for resilience ................................................................................................................ 25
4.1 Resilience principles for the governance of the COVID-19 pandemic .................................. 27
4.1.1 Principle 1 - Encourage a whole of society response through participation and
deliberation ................................................................................................................................... 28
4.1.2 Principle 2 - Improve communication and complexity literacy to build awareness and
understanding ............................................................................................................................... 28
4.1.3 Principle 3 – Promote coordination and interplay management to foster policy
coherence ..................................................................................................................................... 28
4.1.4 Principle 4 - Design interdisciplinary learning systems at the science policy interface 29
4.1.5 Principle 5 - Foster polycentricity to protect the distribution and balance of power .. 29
4.2 Preventive, reactive, and recovery resilience to build robust systems ................................ 30
4.2.1 Health ............................................................................................................................ 30
4.2.2 Social ............................................................................................................................. 32
4.2.3 Economic ....................................................................................................................... 33
4.2.4 Environmental ............................................................................................................... 34
4.3 Systems integration for transformation towards resilience and sustainability .................... 35
5 References .................................................................................................................................... 38

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1 Introduction
As of the start of January 2021, the COVID-19 pandemic has caused more than 1.84 million deaths
globally. With widespread disturbances in health, economic and social systems worldwide, the pan-
demic poses an extraordinary challenge for billions of people around the world. This systemic crisis
reveals how health systems worldwide, and societies more broadly were unprepared to face an
emerging infectious disease such as COVID-19 [1, 2]. Furthermore, the COVID-19 pandemic exposes
shortcomings in our current thinking and governance capacities for tackling complex challenges. This
paper entitled “Building societal resilience to COVID-19 and future pandemics: a synthesis of the liter-
ature and framework for action” aims to improve how societies address emerging infectious diseases.
The core assumption is that countries who use a complexity lens to learn from this unprecedented
crisis will be better placed to build resilient systems and societies in a rapidly changing world.
The development of this paper is based on resilience thinking, which encompasses the capacities of
societies to: 1) prepare, prevent and protect before disruption, 2) mitigate, absorb, and adapt during
disruptions, and 3) restore, recover, and transform after disruption [3]. As an interdisciplinary ap-
proach, resilience thinking is useful for looking at how the COVID-19 pandemic affects globally inter-
connected societies. This, in turn, emphasises the need for governance to assess and address trade-
offs in complex social systems. These complex social systems exhibit a number of properties that make
them hard to understand and govern [4]. As governance is the steering of societies towards collective
outcomes, the scope of governance extends beyond governments to encompass the role and actions
of diverse public and private actors. Resilience thinking stresses the need for new modes of govern-
ance within the context of the growing impact of humankind on the planet [5, 6].
The ambition of this paper is to provide a systemic view of how to govern effectively pre, peri, and
post crises in the globalized world of the 21st century. As building resilience requires an understanding
of the complex nature of the crisis, this paper first takes stock of the origin of the current pandemic.
It also discusses the nature of the responses so far and the impact of different public health and social
measures. In the second part, the paper describes the impacts of the pandemic and identifies enablers
of and obstacles to resilience in the health, social, economic, and environmental systems, thereby
integrating the key pillars for sustainable development, at both national and international levels. Fi-
nally, the paper identifies some lessons learnt and outlines recommendations for governance and pol-
icy to nurture a more resilient society based on wider transformations towards sustainable develop-
ment.
The paper was developed during the summer and autumn of 2020. The lead author (DW) assembled
a team of co-authors from the natural and social sciences based on their expertise and interest in
systems thinking and COVID-19. A first draft was based on a synthesis of the literature led by DW
regarding COVID-19 and the governance of complexity [7]. As resilience to infectious diseases has not
been very well developed, the development of the paper also benefited from the work of the ongoing
AMR-resilience project [8], which is adapting social-ecological resilience to the challenge of antimicro-
bial resistance [9-16]. A literature search on resilience and COVID-19 identified 865 articles published
in peer-review journals. After title and abstract screening, 221 full text articles were read and 150
were included in this paper. A further search on resilience and COVID-19 was done to detect the grey
literature with a focus on the work of international organisations. Additional references about resili-
ence, sustainability and governance from a complexity lens were retrieved using a snowball approach.
To facilitate the paper’s policy outreach, a participatory workshop gathering 23 academics and global
governance stakeholders from International Geneva took place on 26 September 2020. Participants
of the workshop contributed content about systemic effects and helped build the framework for ac-
tion of the paper. Finally, further exchanges about resilience occurred during a University of Geneva

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and University of Zurich Expert Meeting hosted by the World Economic Forum on the 12th November
2020 on Shaping Resilient Societies.
2 Origin of and response to the pandemic through a complexity lens
The linchpin of the COVID-19 pandemic is the social and ecological complexity that has come to define
this early 21st century. Complex systems are “highly composite ones, built up from very large numbers
of mutually interacting subunits (that are often composites themselves) whose repeated interactions
result in rich, collective behaviour that feeds back into the behaviour of the individual parts” [17]. These
open and dynamic systems operate far from equilibrium and exhibit behaviour that cannot be ex-
plained by looking at the properties of their parts [18]. As such, complex systems “give rise to complex
collective behaviour, sophisticated information processing, and adaptation via learning or evolution”
[19]. The growing field of systems and complexity science [19, 20] provides relevant concepts, theo-
ries, and methods to study the current COVID-19 pandemic as a result of complex social and bio-eco-
logical interactions [7]. The following sections examine both the origin of and the response to the
current crisis through a complexity lens.
2.1 Context, drivers, and vulnerabilities
Infectious diseases have always represented a risk to human health. During the first half of the 20th
century, major events included influenza (1918-1920) and cholera (1899-1923) pandemics [21-23].
Major advances in science and technology, alongside improvements in social and living conditions in
many countries over the last century, reduced the global impact of infections on population health by
the latter decades of the 20th century. A sense of confidence grew in high-income countries after the
eradication of smallpox was officially confirmed in 1980, responsible for 300 million deaths in the 20th
century alone, that humanity could tame the perpetual challenge of infectious diseases [24]. However,
by the 1990s, this optimism started to fade with the discovery of many emerging and re-emerging
diseases (such as bovine spongiform encephalopathy and HIV-AIDS). There was also increasing aware-
ness that many infectious diseases, particularly those transmitted to humans from animals (i.e. zoon-
otic diseases), may emerge too quickly to discover and counter with existing and new treatments [25-
28]. In addition to existing threats such as malaria, tuberculosis, HIV-AIDS, and neglected tropical dis-
eases, the 21st century has already faced several infectious disease crises including the 2002-2003
SARS outbreak, the 2009 H1N1 influenza pandemic, the 2014-2015 Ebola virus outbreak in West Af-
rica, and the 2015-2016 Zika virus epidemic [26, 29]. Even where these outbreaks could be geograph-
ically contained, they created economic and social ripple effects well beyond the countries where they
emerged [30-35]. Many warned that lessons needed to be learned from these previous events, but
decisive action was not taken to step up pandemic preparedness [36-39].
The precise animal origin of the SARS-CoV-2 pathogen, which emerged in late 2019, remains unknown
[40, 41]. Research on emerging infectious diseases stresses the importance of multilevel and mul-
tiscale interactions between host, pathogens, and other factors at the human, animal, and environ-
ment interface [42]. Relevant factors known to facilitate the spillover of pathogens from animals (es-
pecially wild animals) to humans, which is often a preliminary step before localized outbreaks hap-
pens, include agricultural disruption of animal habitats, widespread environmental degradation and
trade in wildlife [43-46]. Expanding land use contributes to deforestation and to the increase in human
dominated habitats which have been associated with increasing zoonoses [47]. Growing understand-
ing of the drivers of emerging infectious diseases has led to the identification of global hotspots for
their emergence [48, 49]. From a planetary health perspective, emerging and re-emerging infectious
diseases may be one manifestation of the degradation of the biosphere [50, 51].

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In addition to drivers of emerging infectious diseases, a wide range of vulnerabilities appear to be
affecting how societies are impacted by the pandemic [52]. One category of vulnerabilities are factors
that facilitate the transmission of COVID-19 within a population. First, educational, commercial and
other social settings where people gather and interact such as schools, workplaces, restaurants, bars,
concert halls, alongside the intrinsic social nature of human behaviour, have enabled transmission
between people. Within such settings, populations unable to adapt their behaviours and physically
distance from others, have been especially vulnerable. Societal factors related to the increased risk of
transmission include socio-economic inequities that make people more likely to go to work while sick,
due to the lack of a safety net or insurance [53]. Second, international travel and trade have led to the
spread of the virus between jurisdictions. The globalisation of the world economy and other aspects
of social life has allowed humankind to reach an unprecedented level of development and health
around the world [54]. Globalisation has also been associated with unprecedented possibilities for
people to connect with each other. However, global interconnectedness has also created systemic
risks that favour disease outbreaks, notably regarding their rapid transmission across countries [55-
57]. Third, widespread mis/disinformation can amplify contagion by encouraging inappropriate be-
haviours [58, 59]. Finally, other societal factors might reduce the effectiveness of governmental action.
These may include a low level of trust in government and a high level of individualism which may lead
to resistance to public health directives [60, 61].
A second category of vulnerabilities encompasses factors that increase the impacts of COVID-19 within
the population [62]. These factors primarily concern population health status and the capacity of
health systems. One modelling study found that one in five people could be at risk of severe COVID-
19 [63]. Ageing of populations and prevalence of chronic conditions including asthma, diabetes, and
hypertension have increased the risk of developing severe disease or dying from the coronavirus [64].
COVID-19 is now understood as a ‘syndemic’, where the virus clusters and interacts with pre-existing
conditions that, in turn, are caused and sustained by political, economic, and social factors [65, 66].
Health system vulnerabilities may include a limited trained workforce, financial resources, infrastruc-
ture capacity and medical products and technologies [67, 68]. Austerity policies that followed the fi-
nancial crisis of 2008 have led to under-investment in health systems [69]. The wider political deter-
minants of the crisis are still not understood but racialized groups have faced higher mortality in sev-
eral countries [70-72]. Racism has been identified as the basis of racial disparities in several countries
[73]. There are also important inequalities in the distribution of health care resources among the poor
and the rich [74-76]. Indeed, the responses to the crisis have notably exacerbated existing vulnerabil-
ities such as gender inequality or created new ones [77, 78]. Table 1 summarises relevant concepts
related to the origin of the current COVID-19 pandemic and Figure 1 summarises key drivers and vul-
nerabilities linked to the complex syndemic nature of the pandemic.
Table 1. The origin of the COVID-19 pandemic from a complexity lens
Insights from the study of complex systems
Key features of the COVID-19 pandemic
Multi-layered networks give rise to complex causality. The
underlying drivers for emergent phenomena are often
multiple and heterogenous.
The emergence of COVID-19 results from multiscale
interactions between host, pathogens, at the human,
animal, and environmental interface.
Globalisation has created overlapping global systems that
enable risk arising in one part readily spreading to other
parts. These systemic risks can result in large-scale events.
Increased flows of people have increased the risks of the
rapid transmission of infectious diseases.
Telecoupling refers to interactions between geographically
distant but linked areas [79]. Coupling is among the primary
drivers of vulnerability [80].
Telecoupling includes the diffusion of lifestyles that favours
non-communicable diseases and makes people vulnerable
to an emergent pathogen.

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Figure 1. The complex syndemic of COVID-19, its drivers, and vulnerabilities, adapted from [74, 81,
82].
2.2 The government response to the COVID-19 pandemic
The scale and scope of the response to the COVID-19 pandemic are unprecedented in recent times.
Countries introduced numerous measures including but not limited to public health and social
measures [83]. These included restrictions on population interactions and movements at multiple lev-
els not seen in recent history. Evidence from previous outbreaks suggest that measures are most suc-
cessful when applied at the beginning of an outbreak [84]. However, it is characteristic of epidemics
involving novel pathogens that, during the early stages, there is insufficient information to make evi-
dence-informed decisions [85]. In early 2020, many governments made decisions that resulted in ex-
cess morbidity and mortality because they had insufficient information and little time to recognise the
severity of the spreading epidemic. With the number of cases growing exponentially in the first half
of 2020, public health authorities were unable to conduct timely and effective testing, contact tracing
and quarantine/isolation. To protect health systems from being overwhelmed, governments in many
countries imposed partial or complete lockdowns, characterised by the shutdown of the economy
associated with physical distancing measures [86]. These countermeasures were enabled by the wide-
ranging jurisdictional power of many governments during a time of national emergency. The need to
act quickly, which was amplified by classical and social media channels, tended to favour responses at
the national level, where the main responsibility for public health lies. Globally, there was limited co-
ordination with other (neighbouring) countries [87].
With limited experience of responding to a public health emergency such as COVID-19 [88], many
governments adopted similar approaches. However, there has been considerable variation in terms
of the degree to which policies were implemented and enforced in different parts of the world, rang-

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ing from recommendations to obligations [85]. Some national governments (e.g. United States, Swe-
den) chose not to shut down their economies entirely. Other governments (e.g. United Kingdom) de-
layed their response [89]. In contrast, several countries (e.g. Singapore, Taiwan) rapidly applied strict
travel and screening measures, manufactured diagnostics on a large-scale, and conducted effective
contact tracing [90, 91]. The slow-down of the COVID-19 pandemic in many countries by the spring of
2020 suggested that measures implemented by governments, coupled with better management of
severe cases, was slowing the rate of new infections. Variations in the intensity and timing of the
responses adopted across countries reflected different epidemiological and demographic contexts,
but also different cultural values, levels of socio-economic development, and political priorities [92,
93].
The slow-down of the COVID-19 pandemic in many countries by spring 2020 suggested that lockdowns
coupled with better management of severe cases, the use of face masks, the fast development of
polymerase chain reaction and serologies for testing, and contact tracing, were able to reduce trans-
mission and new infections. While public health and social measures adopted were proving effective
in many settings, they were also causing wide-ranging negative effects [94]. For example, lockdowns
restricted fundamental freedoms such as movement or assembly, in ways that were difficult to fathom
prior to the crisis [95, 96]. This rendered lockdowns unpopular and difficult to sustain especially when
the social welfare and safety net systems are insufficient or non-existent. Lockdown measures thus
prevented people earning a basic income and/or forced them to use any savings they have, effectively
pushing them to the financial brink [97]. Therefore, some lockdowns were accompanied by varying
measures to support selected populations and sectors of the economy (see Figure 2).
With new cases of infection diminishing, lockdowns were gradually relaxed in several countries during
the summer of 2020, while still maintaining and/or refining physical distancing rules. The growing but
limited scientific evidence available [98] led many governments to step-up contact tracing, physical
distancing protocols, quarantine for travellers returning from high-risk areas, and other measures with
an emphasis on wearing a mask (particularly in indoor public spaces), and restrictions on size of social
gatherings (public and private). Despite these measures, an initially slow, but sustained increasing
trend in transmission occurred in many countries, notably in Europe, at the end of the summer in
2020. Transmission rates started to rise again, particularly among younger adults, with initially a lim-
ited number of hospitalisations and deaths. However, in the fall of 2020, many countries experienced
a second wave of infection characterised by a new increase in excess mortality. Governments have
responded with the re-introduction of stronger restrictions including varying forms of lockdown, alt-
hough in more geographically and temporally contained forms.

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Figure 2. A wide palette of measures targeted at the individual and collective levels. Based on the
COVID-19 Government Measures Dataset [99] and OECD Key policy responses [100]. The figure was
derived using a template from https://slidesgo.com/
2.3 Ongoing challenges to effective public health responses
While it is hoped that effective scientific advances, notably vaccines, will soon significantly shift the
trajectory of the COVID-19 pandemic, several ongoing challenges remain. Despite enormous scientific
progress in understanding COVID-19 over 2020, a number of uncertainties regarding the virus and its
effects on and interactions with the human body hampers both the current response and reopening
scenario. An important source of uncertainty is the development and maintenance of immunity in the
population, with or without a vaccine [101]. How vaccines will trigger an immune response and
whether or not they will work for some vulnerable groups such as the elderly or those who are obese
and overweight will influence the course of the pandemic [102-104]. These knowledge gaps regarding
the immune response are in turn the source of uncertainty regarding whether the virus will become
endemic [105], which would require sustained mitigation or suppression strategies, or whether a
strategy of elimination is possible [106] (see Box 1 on the limits of predictive modelling).
Multimodal strategies are effective but the wider capacities to respond are still not well understood.
Since the beginning of the pandemic numerous public health and social measures have been adopted
by governments. Some measures such as wearing a mask have been more contentious than others.
Pre-existing analytical tools for evaluating public health capacities, many of which have been devel-
oped from a global health security perspective (e.g. global health security index) [37, 107, 108], in-
cluding the Joint External Evaluation related to the International Health regulations [109-112], have
limited explanatory power when it comes to a country’s capacities to tackle the COVID-19 pandemic.
Analysis of the responses in different countries is leading to a growing understanding of the individual
measures needed to address the COVID-19 pandemic. A recent study examining non pharmaceutical
interventions adopted in European countries suggested that particularly effective ones include “clos-
ing all educational institutions, limiting gatherings to 10 people or less, and closing face-to-face busi-
nesses” but that “the additional effect of stay-at-home orders was comparatively small” [113]. How-
ever, our understanding of how these measures interact together, and in combination with other mul-

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tiple factors, to effectively control transmission is more limited. Finally, because extended non-phar-
maceutical interventions increase the number of susceptible for a range of endemic infections, this
might result in large outbreaks in the future [114].
Because addressing the COVID-19 pandemic is a multi-objective problem under deep uncertainty
[115], the question of societal trade-offs is a pressing matter of contention. The detrimental effects of
some public health and social measures on education, business, and social life generate tension be-
tween controlling virus transmission while sustaining the functioning of societies. At the social level,
prolonged school closures are deemed unacceptable by a large part of the population because of the
dampening of household productivity in the short term and the impacts they have on the next gener-
ation in the long term. Public health and social measures that affect the economy more directly are
also being contested. For some, it is unacceptable to close the economy as it generates unemployment
and other wide-ranging societal effects. Others argue that countries who better contained the out-
break during the spring 2020 were less vulnerable to an economic downturn compared to countries
that were unable to control the outbreak [116]. Moreover, some economists argue that a strong public
health response will support the economy in the longer term [117, 118]. While the full impact of the
COVID-19 pandemic will only become visible in the long-run, some argue that protecting the economy
is essential to protect life now and later [119]. The debate about trade-offs takes place within govern-
ment bodies and sometimes operates across governance levels. In some instances, with stark differ-
ences between the measures adopted at the sub-national level by national governments [120], local
constituencies want to be able to decide for themselves, especially when measures strongly impact
the local economy [121]. However, the traction of local measures might be limited by macroeconomic
trends playing at the national level [122]. Overall, many governments are currently struggling to bal-
ance different objectives which complicates communication with the public.
Policy resistance hinders the effectiveness of public health and social measures in different contexts.
Many governments are confronted with non-adherence or partial adherence of their population with
measures stemming from a lack of trust in government and/or science [123], the need to make difficult
choices, or perceived infringements on individual rights and freedoms. While a strong and effective
national response can build trust [124], perceived lack of effectiveness of and frequent change in pub-
lic health and social measures can erode confidence in government. This phenomenon is exacerbated
when public health communication does not recognise uncertainties [125]. As governments push to
enforce measures, a vicious circle may occur between command-and-control approaches that create
mistrust, and lower adherence. In some cases, this has led to public demonstrations against COVID-19
measures. Because the public health response is associated with the government, this can further
prevent some people from participating in the public health response. This phenomenon is illustrated
by the low adoption by the population of government endorsed COVID-19 contact tracing in most
countries that use such technologies [126]. In addition, the state of emergency provides a way for the
state to make decisions quickly and take decision action. However, the reinforcing of the powers of
the executive branch may risk compromising fundamental rights and institutional checks and bal-
ances. Excessive and disproportionate measures have already been adopted in many countries [127].
Against a rise of populism fuelled by mis/disinformation, the instrumentalization of the public health
emergency response raise further fears of more authoritarian pathways in some countries [128-130].
Finally, intricate dynamics related to the interactions between the epidemiological and behavioural
components of the pandemic can prevent effective response [131]. Some countries that were initially
less impacted by the COVID-19 pandemic have been hit harder by a second wave. Relative success in
taming the first wave may have made these countries more vulnerable because public health and
social measures were perceived as superfluous by some part of the population [132]. Other related

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behavioural phenomena might include a rebound effect. The more stringent the public health re-
sponse is, the more people may want their freedom back after its relaxation and compensate for the
lack of social interactions. An important related problem is about sustaining behaviour change over
time [133]. People are prone to adopt measures when they perceive a risk as imminent. The simplified
narrative of a single event in the spring of 2020 might have contributed to the relaxation of the adher-
ence to public and social measures in the summer 2020. Finally, the challenge of safely re-opening
societies is also linked to dynamics of globalization. Countries need to find way to limit the re-impor-
tation of cases once they have controlled the epidemic [134]. This has proven difficult in regions that
are economically, culturally and politically integrated.
Box 1 – Challenges in epidemic modelling & forecasting of COVID-19
Decisions to apply public health and social measures during the COVID-19 pandemic are largely influenced by
the use of different types of modelling methods [135]. These models may be roughly divided into three types:
(i) mechanistic models [136, 137], (ii) purely data-driven models [138], and (iii) hybrid models. Most classical
epidemic models are mechanistic and try to describe disease dynamics in terms of interacting “agents” on pop-
ulation, meta-population, and individual levels. Such models are usually applied to describe the influence of
certain factors (e.g., population density, demographics, interaction networks, mobility, etc.) on the actual dis-
ease dynamics. Data-driven or machine learning models make fewer assumptions about the underlying dynam-
ics and are applicable to a broader range of prediction problems, but they also come with the cost of less inter-
pretability for policymakers and epidemiologists. In other words, there is a trade-off between prediction and
explanation.
Many of the previous research efforts in computational epidemiology have been devoted to a posteriori epi-
demic modelling. But unfortunately, even in cases when predictions with confidence intervals are being provided
(e.g., during the current COVID-19 pandemic), appropriate statistical evaluation of predictions is not carried out
in a unified way. Therefore, it is unclear which types of models are able to make the most accurate predictions
of outbreak characteristics during an epidemic. Several epidemic forecasting initiatives were launched to test
the accuracy and accelerate scientific innovation of different epidemic modelling frameworks during the current
SARS-CoV-2 outbreak. A relevant example is “Epidemic Datathon” (https://www.epidemicdatathon.com/), an
international collaboration, that allows researchers to submit and compare their COVID-19 case number predic-
tions for different countries in real-time by using the corresponding case data of the COVID-19 Data Repository
by Johns Hopkins Center for Systems Science and Engineering as ground truth [139].
In Figure 3, two different epidemic forecasting frameworks – a mechanistic susceptible-infected-recovered (SIR)
model and a data-driven prediction method – are used to (a) predict the evolution of confirmed COVID-19 cases
in Italy and (b) compare their accuracy across 15 different countries from the beginning of March 2020 until the
end of May 2020. Our purely data-driven predictions are based on Euler’s method (red solid line). In this method,
we use the rate of change of a quantity (e.g. the number of confirmed cases or deaths) at time
to predict the value of this quantity at a time according to
(1)
The uncertainty of Euler forecast estimates, can easily be made by assuming observational noise with specific
variance. In the SIR model-based predictions (green solid line), we use susceptible, infected, and recovered com-
partments , , and and transition rates and to model infection and recovery pro-
cesses. The corresponding rate equations are
(2)
where is the population size. Additional states and transitions can be helpful to account for
latency periods, hospitalisations, and quarantine. In figure 3, we fit the cumulative number of reported COVID-
19 cases to empirical data. The evolution of C(t) = I(t) + R(t) is described by

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(3)
where is the fraction of reported cases. The results shown in figure 3 suggest that the prediction results ob-
tained with Euler’s method are more accurate than those obtained with an SIR model, which is commonly used
in epidemic forecasting.
Figure 3 Accuracy of different epidemic prediction frameworks during the initial COVID-19 outbreak
Legend: Two different epidemic modelling frameworks are used for forecasting: (1) Euler’s method (red solid line), which is
a purely data-driven model, and (2) a commonly used mechanistic epidemic SIR model (green solid line). On each day t, both
models are fitted to historical data and corresponding case-number predictions for a t+7 days rolling window are made
(across 15 different countries including Italy, Germany, USA, Spain, and the United Kingdom, see https://www.epidemicdat-
athon.com/ for details). (a) We show the number of confirmed SARS-CoV-2 cases in Italy (black disks) with model predictions
(solid lines) and confidence intervals (shaded regions). (b) Prediction accuracy of confirmed SARS-CoV-2 infections. We ob-
serve that the simple data-driven Euler method outperforms SIR model predictions, highlighting that policymakers and do-
main experts have to be aware of possible limitations and assumptions of common epidemic forecasting frameworks.
3 Systemic effects and societal resilience
Analyses of the context, drivers, vulnerabilities, and responses to the COVID-19 pandemic to date re-
flect the unprecedented complexity of the current crisis. The interplay between different factors re-
garding the origin of and responses to the pandemic has created a complexity timebomb characterised
by mismatches between spillover at the One Health interface and population and systems’ vulnerabil-
ities, the lack of pandemic preparedness and a rushed policy response dominated by linear thinking
and a simplified narrative (Figure 4). The most striking feature of the COVID-19 pandemic is its pro-
found disruption to almost every society worldwide in its entirety. High levels of connectivity and cou-
pling created pathways for the initial manifestations of the crisis to propagate and amplify. For disrup-
tions that have a high potential of propagation, such as COVID-19, the initial failure to contain the
outbreak sufficed to trigger a massive disruption of the system. Both the course of the pandemic, and
the responses to it, have had effects that are often surprising, non-linear and difficult to predict. The
COVID-19 pandemic, in short, has generated wide-ranging systemic effects [140] (Table 2 relates these
systemic effects to the properties of complex systems). In this context, there are two major limitations
regarding current analytical approaches to the crisis. First, traditional disciplinary-specific approaches
remain essential. However, the complex nature of the crisis requires a more holistic transdisciplinary
view as well. Second, current approaches have stressed the role of individual governments in imple-
menting different measures but have often neglected the role of other actors and systemic factors in
the response. Alternatively, a complexity lens can examine the capacity of societies, as whole systems,
to face large-scale disruptions [7].

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Figure 4. The complexity time-bomb of the salient features of the COVID-19 pandemic
Table 2. Systemic effects and non-linear dynamics: the nature of change in complex systems
Key features of the COVID-19 pandemic
Insights from the study of complex systems
COVID-19 spreads by direct contagion, leading to
exponential growth when R0 > 1. Superspreading events
lead to the contagion of many more persons than average
[141, 142]. Widespread disinformation about COVID-19
can amplify the spread of infectious diseases and vice-
versa [58, 131, 143].
In classical contagion, exposure to a single infected
individual increases transmission. Transmission can follow a
power law distribution where some individuals cause most
subsequent cases. Complex contagion requires contact with
multiple sources of reinforcement to be transmitted [144].
(Lack of) actions to tackle COVID-19 has led to failures in
other systems such as education and the economy. At
times, effects may be delayed. E.g. lockdowns have led to
schools’ closure which may contribute to higher drop-out
rates.
In cascading failure, the failure of one component of the
system leads to failures of other interconnected
components. The resulting amplification leads to outcomes
that are difficult to predict and control [145].
A threshold was crossed when the localised epidemic of
COVID-19 became a pandemic. Given its global spread,
COVID-19 might become endemic with possible seasonal
patterns. Societies may have to learn to live with it.
A threshold is a point that triggers change once passed. A
tipping point describes minor event can lead to
disproportionate change in the system [146]. A bifurcation
is an irreversible change of the trajectory of a complex
system.
COVID-19 is triggering changes in human interactions with
effects on transportation, remote working, public
gathering, and behavioural expectations. Reversibility
depends on how the pandemic can be controlled.
A system shift describes a major change in a system’s
feedback and behaviour. Hysteresis happens when a return
to the conditions at which the shift occurred is not sufficient
for the system to come back to its original state. The system
settles in a new dynamic equilibrium which may be stable
or not.
Applying a complexity lens to analyse the impacts of, and needed responses to, COVID-19 in terms of
societies as whole systems, leads to a focus on societal resilience. Resilience stresses both purposive
actions to tackle an issue, and the broader contextual determinants and vulnerabilities that can affect
those actions (Box 2 explains in more detail the multiple meanings of resilience) [147-149]. A resilient
society: 1) identifies threats and opportunities to prepare, prevent and protect before disruption (pre-
ventive resilience), 2) responds effectively in the event of an emergency to mitigate, absorb, and adapt
to the disruptions (reactive resilience), and 3) mobilises its resources to restore, recover, and trans-
form after disruption (recovery resilience) [3, 150]. Resilience can be built into different systems in-
cluding the economic, social, health, and environmental, as well as across different scales of social and

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political organisation - individuals [151], families, communities [152], organizations [153], and coun-
tries [154]. Hence societal resilience to the COVID-19 pandemic can be defined as the capacity to re-
duce the spread and impact of the disease while mitigating other undesirable societal effects. Because
contemporary societies are highly interconnected, the pandemic of COVID-19 is testing not only health
systems resilience but also economic, social, and environmental resilience as three interdependent
systems of sustainable development (Figure 6 illustrates this interdependence). While the empirical
evidence about resilience to pandemics is limited, the section below provides examples of systemic
effects and relates them to the capacity of different actors and systems to cope, adapt and transform.
Box 2 – Resilience and complex systems: What are we talking about?
Resilience thinking originated in engineering and ecology, was then used in psychology and psychiatry, and has
more recently been further developed in areas such as disaster management and response [155, 156], and the
governance of social ecological systems [4, 157-159]. Resilience can be expressed in different ways and has been
criticised for lacking conceptual clarity [160]. In the engineering literature, resilience is the ability of a material
to bounce back to its initial state after an elastic deformation. While this definition focuses on materials, resili-
ence has also been applied to complex systems. Through a complexity lens, resilience refers not only to the
capacity to absorb a shock but also to the capacity of a system to evolve to a new state characterised by different
feedbacks and behaviours [161, 162]. In other words, both the components and their interactions can be re-
modelled following a shock to either continue to perform the same function (adaptive capacity) or to change
the goal of the system (transformative capacity). This means that resilience is “both about adapting to the ex-
ternal world and about being aware that in this process of adaptation the world is being reshaped” [163].
Resilience thinking is well-suited to studying situations where a complex system faces disturbances and must go
through cycles of adaptation to persist in the long-term, in particular when these dynamics occur at several
scales of the system [164]. Disturbances of complex adaptive systems can be characterised in terms of their
temporal evolution [165]. In figure 5, Panel a) present real-world data in three interelated area of health (blue
line), restrictions on social interactions (red line), and economic impact (green line) during the first wave of the
pandemic. Panel b) shows that a country exhibits some level of deviations along the selected dimensions at any
point in time. Panel c) is about relevant resilience measurements. Performance tends to naturally oscillate in
complex adaptive systems. When a serious adverse event occurs, this results in a reduction of system perfor-
mance. The impact on the system can be described in terms of the 3Rs [165, 166]. The first ‘R’ is for robustness
which is the intensity of disturbance a system can withstand and still maintain its function above a certain thresh-
old of performance. The second ‘R’ is for resistance, which measures how much performance is reduced or,
conversely, the ability of a system to deflect disturbance and avoid impact. The third ‘R’ is for recovery time, i.e.,
to return to previous system performance following a disturbance. In some cases, a system cannot simply return
to initial conditions, it has to adapt or even transform to new conditions. Panel d) uses the ball and cup heuristic
of resilience.

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Figure 5 Measuring resilience (panel c is inspired by Grafton et al. [165], panel d) is inspired by Gunderson
[167].
Resilience is not necessarily desirable from a societal standpoint. For example, the use of fossil fuels in transpor-
tation has so far proven resilient to the emergence of new technologies. Hence, resilience has been criticised in
several areas for ignoring power relations and political agendas [168-171]. When exclusively defined as a recov-
ery process, resilience can neglect the capacity to prevent and to anticipate shocks leading to costly inaction.
Furthermore, a narrow definition of recovery might prioritise a return to the ‘normal conditions’ [172] to the
detriment of adaptation or transformation, even when ‘normal conditions’ are suboptimal or not desirable. This
is particularly relevant regarding sustainability. Resilience and sustainability are different concepts where resili-
ence can be understood as a component of sustainability or vice versa, two separate objectives, or two compo-
nents of a common vision [173]. While sustainability is about the long-term maintenance of well-being within
planetary boundaries [174], resilience is about facing events that may jeopardize the provision of societal func-
tionalities [175]. The key aspects to address when using resilience is 1) resilience of whom/what (e.g. stakehold-
ers/systems), 2) resilience to what (e.g. disruption or phenomenon), and 3) resilience for whom (i.e. who bene-
fits and loses from applying resilience) [171, 176].

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Figure 6. A blueprint to build societal resilience to COVID-19 and future pandemics across systems
From a societal perspective, the primary focus in examining systemic effects and resilience to health
threats are at the local and national levels that are entrusted with the responsibility for public health.
The distribution of power between the local and national levels will thereafter depend on the level of
centralisation of the relevant State. Local and national resilience have been associated with building a
consensual narrative, mobilising appropriate resources in a timely fashion across sectors of the econ-
omy, and continuing essential economic and government functions during a crisis [177]. Factors such
as trust in national government and public institutions, sense of belonging, and social integration are
also used to assess national resilience [154]. By contrast, limited financial and human capacities, lack
of trust in public institutions, high inequalities, and the absence of rule of law have been stressed as
factors that reduce societal resilience [178-180]. Overall, these factors stress the role of government(s)
to respond in a timely fashion. However, resilience thinking extends beyond governments and requires
examining a larger number of agents including individuals, families/households, communities, and
public and private organisations. The action of these agents underpins the constant adaptation of so-
cieties even with limited control from governments [181, 182].
Strengthening national capacities to respond to the COVID-19 pandemic is critical but the current
COVID-19 pandemic is a global crisis of an interconnected world. Because COVID-19 easily spreads
across borders, there is also a need for a coordinated response in affected systems at the global level.
Fostering coordination at the global level is challenging because of major differences in values and
political agendas. These differences are amplified in times of crises, especially in the context of other
major concurrent geopolitical issues. States are traditionally the main actors in international relations,
but multinational companies, NGOs, grassroots organisations, and transnational networks have in-
creasingly taken centre stage. Societal resilience at the global level primarily relies on interactions
between these actors. Overall, the drivers of resilience can be situated in different systems, scales of
social organization and levels of governance. Resilience to the COVID-19 pandemic can be seen as a
multi-layered network characterised by interactions among and between resilience factors across sys-
tems, scales of social organisation, and levels of governance (figure 7).

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Figure 7. Resilience to the COVID-19 pandemic as a multilevel network of interconnected drivers and systems
3.1 Health
Health systems, which encompass all the activities “whose primary purpose is to promote, restore
and/or maintain health” [183], have been the first line of defence against the COVID-19 pandemic.
Resilient health systems are those that can nimbly meet significant increases in demand for both pub-
lic health and healthcare services and adapt to long-standing epidemiological changes [184, 185]. The
COVID-19 pandemic required a mobilisation of many different interconnected components of health
systems supported by adequate governance mechanisms [186]. The shortcomings and weaknesses of
health systems in low- and middle-income countries have been studied for a long time, but the COVID-
19 pandemic reveals the under-studied and poorly understood weaknesses within more performant
health systems. While health systems’ attributes have been proposed to evaluate health systems’ re-
silience [187, 188], few evaluations have been conducted and resilience metrics are still lacking [189-
191]. Overall, it appears that health systems’ resilience is linked to the large variations in excess mor-
tality among different countries [192].
In the context of COVID-19, healthcare resilience primarily implied the capacity to absorb the increase
in demand for health services, particularly in intensive care [185, 193]. Some reserve capacity usually
exists in health systems which is used to absorb seasonal increases in demands [194, 195]. After hos-
pitals in Northern Italy were overwhelmed with COVID-19 patients in the early spring of 2020, many
countries augmented the capacity of hospitals to cope with the exponential surge of patients requiring
treatment for COVID-19. Health resources were reallocated for the treatment of COVID-19 and some
countries more than doubled the number of intensive care beds [193]. Furthermore, some countries
were able to redistribute care between public and private hospitals [196, 197]. It has been argued that
decentralised but partly redundant health systems (e.g. Germany) were better able to cope than more
centralized healthcare system (e.g. the United Kingdom) [198]. The capacity to handle severe cases
was limited by both the unavailability of the health workforce and technologies against COVID-19. In
addition, a dearth of personal protective equipment triggered a snowball effect in infections from

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patients to healthcare workers [199, 200], which further reduced the capacity to absorb the increased
number of patients requiring intensive care. Overall, measures adopted to increase capacity have not
been sufficient to meet the needs during the first and second waves of the COVID-19 pandemic. Con-
sequently, countries were faced with difficult ethical choices (‘triage’) in terms of who should be ad-
mitted to intensive care and who should not. During the first two waves of the pandemic in Europe,
the use of ethics consultation services in the hospitals, advance directives/advance care planning and
triaging guidelines have been critical for avoiding arbitrary treatment [201]. Ultimately, the manage-
ment of mass fatalities has posed acute problem in several countries [202].
The health workforce is critical for the resilience of healthcare systems. Many countries have relied
on the reallocation of healthcare manpower and on the support of students and retired healthcare
workers to cope with the surge in medical needs [203]. The adaptation of the medical and nursing
practice has required unprecedented level of flexibility from healthcare workers [204]. Since the be-
ginning of the pandemic, they have been exposed to high levels of psychological distress and physical
exhaustion [205, 206]. This in turn is hindering the quality of care [207], putting healthcare workers at
risk of burnout or post-traumatic stress disorder, which can have long-term consequence on the men-
tal health of healthcare workers [208, 209]. Women are more vulnerable as they represent the bulk
of the health workforce and continue to be at the heart of the healthcare response whilst juggling
parental and domestic responsibilities [210, 211]. General risks factors for the risk of burnout of
healthcare professionals include organisational issues, such as the workload and non-efficient work
processes, and individual factors such as age, family responsibilities, and personal traits [212]. Resili-
ence of healthcare professionals during disease epidemics can be supported by a range of pharma-
ceutical and psychological support interventions in association with proactive hospital management
[213, 214].
Beyond the capacity to treat infected patients, health systems’ resilience also depends on the capaci-
ties not only to detect and to correctly understand the first signs of a crisis, but also to adopt rapid
countermeasures to safeguard public health. COVID-19 stressed the importance of quickly mobilising
public health resources to reduce disease transmission by identifying those individuals who are at risk
and isolate those that are infected. Countries or regions that were better prepared and quick to react
resisted the shock better [215]. A particular challenge was to protect people living in care and nursing
homes and assisted living communities since residents were particularly at risk of complicated COVID-
19 and concomitantly experiencing loneliness and deprivation of their fundamental rights [216-218].
The extended neglect of long-term care in some countries is thought to have exacerbated the effects
of the COVID-19 pandemic on the elderly [219]. Moreover, in many countries, weak primary care sys-
tems have been unable to strongly support public health measures such as enhanced hygiene prac-
tices, isolation, physical distancing, and stay-at-home quarantine [220]. Even now, contact tracing
faces several challenges due to the nature of the transmission of the disease and the acceptance of
contact tracing and self-quarantine by members of the population [221]. Critically, the acceptance of
such measures relies on public trust and transparent decision-making [222].
Public health agencies and public and private hospitals bore the brunt of the crisis, but other actors
were instrumental for health systems resilience. In some countries, the military provided logistical
support to health systems stressing the biosecurity approach to global health [223, 224]. Community-
engagement also supported several aspects of the public health response [225]. The adaptive capacity
of private companies was demonstrated by reallocating some of their production capacities to address
shortfalls in protective and medical supplies [226]. With the support of governments, the pharmaceu-
tical industry also directed unprecedented efforts to develop technologies including vaccines [227].

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As of the 3rd September 2020, the global COVID-19 vaccine Research and Development landscape in-
cluded 321 vaccine candidates [228]. As of early January 2020, five of them have shown promising
efficacy in phase 3 clinical trials and 3 have received approval for use by regulatory authorities [229].
While health information system are an essential building block of health systems [230], another im-
portant area of development was the use of information and communication technologies which are
increasingly used to monitor and help control the epidemic [231-234]. However, the adoption of gov-
ernment endorsed COVID-19 contact tracing application has remained relatively low in most countries
that use such technologies, partly in relation to the many ethical and governance issues associated
with the use of such technologies [235-237].
The limited resilience of local and national health systems led to the prioritisation of COVID-19 over
other health issues and a reduction in health-seeking behaviours for other diseases. This was in part
due to the closure of in-person appointment in medical practices during the early phase of the pan-
demic in spring 2020. Telemedicine helped ensure the continuity of care for chronic patients [238].
However, several countries reported a decrease in hospital admissions for acute myocardial infarc-
tions [239]. Other effects included the impact of the rescheduling of elective operations, and of redi-
recting efforts from chronic diseases, which traditionally represent a greater health burden to devel-
oped countries [240]. While public health countermeasures might decrease the transmission of other
infectious diseases, an increase of some risk factors associated with COVID-19 is possible [241]. Some
developing countries reported a reduction in immunisation uptake in children [242, 243] or the real-
location of resources from Malaria programmes [244]. Overall, effects on health systems are already
widespread but the full impact on population health will take time to unfold [245].
From a global perspective, surveillance, emergency response, and transborder regulations are the
main components of global containment strategies [246-248]. Since the 1990s, several binding and
non-binding international instruments have been adopted to strengthen surveillance and response to
emerging infectious diseases, against the background of transformation in global health governance
[249-251]. The legally binding International Health Regulations provide the current framework for pre-
venting and responding to emerging infectious diseases at the global level [112, 252]. However, since
they came into force in 2007, they have suffered from a lack of institutional capacities [253] and mean-
ingful enforcement tools to encourage compliance of states [37]. This has resulted in a dysfunctional
system where valuable information can be concealed from the international community. As time is of
the essence when it comes to the spread of infectious diseases, any delay in the dissemination of
information can hamper our ability to prepare for systemic shocks which in turn lowers global societal
resilience.
During the COVID-19 pandemic many countries have disregarded the International Health Regula-
tions. Despite regular World Health Organization advice on travel and other measures, many countries
unilaterally adopted measures that included border control or closure as well as severe entry re-
strictions for foreigners/non-residents in order to reduce the risk of introduction of COVID-19 by in-
ternational travellers [87]. Several months after the start of the crisis, countries still use their own
systems to assess and impose quarantines on travellers from countries or zones they consider a high
risk. Overall, the limited coordinated action between countries suggests a lack of resilience of the in-
ternational legal system. Many of these issues were already identified after the Ebola outbreak [36,
254] but did not result in the necessary reforms within global health governance [250].
Coordinated international actions in human health are critical to fostering resilience. However, adopt-
ing an intersectoral One Health lens between human, animal, and environmental health is also imper-
ative for building resilience, as important drivers of the emergence of infectious diseases are situated
at their interface (cf. section 2). In recent years, the Tripartite Alliance composed of the World Health

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Organization, the Food and Agriculture Organization of the United Nations, and the World Organisa-
tion for Animal Health have defined a common agenda [255, 256]. Efforts at addressing issues jointly
have been realised in different areas including antimicrobial resistance. However, there is yet to be a
global early warning system that allows for early identification of an emerging pathogen with pan-
demic potential.
Because innovation and access to health technologies are vital for reducing the burden of infectious
diseases, another important interface is the one between public health, intellectual property, and in-
novation. Market-driven globalisation has been essential for developing and supplying critical tech-
nologies including vaccines, antimicrobials, and diagnostics [257]. However, market failures have be-
come vulnerabilities in the global response to infectious diseases. The global market-based model for
innovation is effectively unable to provide technologies to counteract global health threats such as
emerging infectious diseases and neglected topical diseases [258]. Moreover, the intellectual property
regime regulating access to medicines partially prevented essential resources from reaching the most
vulnerable and in need. The development of public-private partnerships has increased access to es-
sential medicines in many parts of the world. However, there remain critical gaps in the global gov-
ernance framework for access to medicines [259]. The current and expected limited availability of
COVID-19 vaccines poses a difficult distributional problem both within and between countries [260,
261]. This stresses the importance of new business models, regulations, and overarching ethical
frameworks rooted in the respect for human rights to ensure a fair and effective response. The COVAX
initiative represents efforts by two thirds of countries worldwide to provide equal access to vaccines
by pooling demand [262].
3.2 Economic
Many countries are experiencing the worst economic downturn since the Great Depression with a
shock affecting both supply and demand [263]. From a societal perspective, economic resilience rests
upon limiting the magnitude of economic losses, recovering quickly, and forging new developmental
paths for prosperity [172]. It can be applied at different levels from the micro-economic to the macro-
economic [264]. At the microeconomic level, organisational resilience is mainly formulated around
the management of natural disasters [265]. Relevant factors may include the type of business (size),
financial situation, exposure to customer loss as well as leadership and business culture [266, 267].
The size, position and centrality of firms in the supply chain network can also influence the impact of
disruptions [268]. In the wake of the pandemic, it seems that globally connected firms with the most
market power were less affected than other firms [269]. By contrast small and medium sizes business
have been particularly prone to liquidity problems [270, 271]. As a particularly important risk for com-
panies was to become insolvent, resilience also relied on governmental support [272, 273]. For exam-
ple, some countries provided help in terms of loans, subsidies, and deferrals of taxes. To avoid a strong
rise in unemployment, financial assistance to businesses was further increased in the form of benefits
for employees or partial unemployment compensation schemes.
Micro-economic resilience also concerns how households cope with economic hardship by modifying
their behaviour [274, 275]. Factors such as high household debt can limit the capacity to cope with a
sudden shock [276]. The nature of employment contracts is also important to avoid the financial hard-
ships of precarious employment conditions such as temporary work [277, 278]. Often, people in pre-
carious labour conditions are employed in the sectors of the economy most affected by the pandemic
such as retail [279]. As such, social welfare including unemployment benefits, paid sick-leave schemes,
health insurance, and food distribution was particularly important to mitigate the initial socio-eco-
nomic impact on households [280, 281]. Social welfare was also critical to support adherence to public

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health responses and stress alleviation of individual people, who could not work because of social
distancing measures.
At the meso-economic level, which refers to the economic sector or individual market, the nature of
economic activities often dictated how well different sectors were able to respond to the crisis. For
instance, some economic sectors could easily be shifted remotely or could integrate personal protec-
tion and social distancing measures such as primary (e.g. agriculture) and secondary sectors (e.g. in-
dustry) [282]. These sectors resisted the initial slowdown better. By contrast, some industries such as
catering had to re-design their business for delivery [283] or change their business model [284]. The
impact on the tertiary sector (e.g. services), notably tourism, hospitality, transportation, and cultural
activities was dramatic. The global reduction in tourism could cost as much as 3% of GDP in the worst
affected countries [285].
At the macro-economic level, resilience has been defined in the context of natural disasters as both
“the ability to limit the magnitude of the immediate loss of income for a given amount of capital losses”
and “[…] the ability to reconstruct and recover quickly” [286]. Why some countries performed better
than other is still not well understood. A relevant explanation for variations in economic resilience
might be differences in terms of when different regions of the world were affected by the crisis [287].
Another factor relates to the role of governments. Since the Great of Depression of the 1930s, Keynes-
ian economics has stressed governmental measures in times of depression or crisis. Particularly, fiscal
space for public policy, in other words low debt-to-GDP ratio, is considered an important factor to
counter macro-economic shocks [288, 289]. Preserving economic output partly explains why some
governments did not adopt blanket lockdowns in the early spring of 2020 [290]. However, even gov-
ernments that did not adopt such blanket lockdowns had to support the economy to avoid cascading
macro-economic effects. Indeed, having a good financial buffer has allowed some governments such
as Germany and Switzerland to save entire sectors that would have drowned under the pressures of
the epidemic. Finally, as financial markets have also been affected by the COVID-19 pandemic, central
banks were quick to step in from the onset of the pandemic in early 2020. The response generally
included easing monetary policy, asserting the role of the central bank as a lender of last resort, and
developing new targeted credit schemes for non-financial actors such as firms and governments [291].
From a global perspective, economic resilience encompasses international trade and financial imbal-
ances [292, 293]. The COVID-19 pandemic has clearly revealed vulnerabilities and resilience in this
arena. As an example of vulnerability, a large proportion of the goods consumed worldwide are pro-
duced in a few countries. Disruptions in these countries therefore destabilise globally interconnected
supply chains [294, 295]. In the most extreme cases, the production of some goods is fully localised,
which makes it particularly vulnerable to shocks. A modelling study found that the duration of lock-
down and the number of countries involved were associated with the magnitude of economic losses
[296]. Here the capacity to recover by the reorganisation of global supply chains should be distin-
guished from the capacity to withstand a disruption and continue production. The latter capacity is
for example critical for the availability of medical supplies [297]. From a purely economic point of view,
it makes sense to have production concentrated in one location with the greatest competitive ad-
vantage. By contrast, resilience thinking stresses the need to balance short-term efficiency gains with
longer-term stability and diversity of supply and production chains.
The cumulative effects of economic and financial disturbances due to COVID-19 and its associated
responses, are triggering a global recession [298-300]. Coordinated responses could alleviate effects
on the global economy, but concrete efforts at the global level have so far been limited. In March
2020, the G20 “committed to do whatever it takes to overcome the pandemic” [301] while the World
Bank has emphasized debt cancellation and the International Monetary Fund (IMF) has increased its

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lending capacity [302]. Some joint efforts have been made at the regional level. For example, the Eu-
ropean Union has sought to sustain the economy through both fiscal and monetary policies. In March
2020, the European Commission adopted an unprecedented measure with the activation of the gen-
eral escape clause of the Stability and Growth Pact (SGP) [303]. The European Central Bank also
launched a large emergency private and public bond purchase programme, the Pandemic Emergency
Purchase Programme (PEPP). In July 2020, the European Union setup a recovery instrument called
‘Next Generation EU’ endowed with €750 billion [304]. These efforts are promising yet their effects in
the long-term are not known.
3.3 Social
The COVID-19 pandemic has exposed people to a complex array of stressors [305] with already far-
reaching social consequences. Social resilience results from the different scales of societal organisa-
tion including individual, family, community and society and their interactions [306]. At the individual
level, most definitions of resilience are based on the capacity to face adversity and to adapt to chang-
ing circumstances [307]. General relevant personal qualities include self-regulation, problem solving
and learning, motivation, and persistence [308]. Beyond these personal qualities, individual resilience
“is best understood as the process of multiple biological, psychological, social, and ecological systems
interacting in ways that help individuals to regain, sustain, or improve their mental wellbeing when
challenged by one or more risk factors” [309].
The pandemic is profoundly intersected with mental health, resulting in increased symptoms of anxi-
ety, stress, and loneliness among many other mental ailments [310-313]. The fear for relatives has
been reported as an important stressor [314]. Social connectedness is critical in time of crisis [315],
yet public health countermeasures specifically aim at reducing social interactions [316]. Effectively, a
longer duration of quarantine was associated with higher levels of mental distress [317]. In conjunc-
tion, an increase in substance abuse was also reported [318, 319]. Adverse effects on populations’
mental health also increased domestic violence, and child abuse and neglect [320, 321]. Resilience of
individuals and families is influenced by pre-existing vulnerabilities such as prior physical and mental
health issues, trauma, and psychological traits such as intolerance to uncertainty. Socio-economic fac-
tors include economic hardship, marginalisation, and dysfunctional family relationships [322, 323].
Resilience of individuals to the COVID-19 pandemic may be increased by factors as diverse as en-
hanced individual autonomy, perceived social support, sleep quality, getting outside and exercising,
and artistic activities [324-328]. Psychological interventions can also help the population cope and
adapt to the disruptions caused by the pandemic [329, 330].
At the community level, the COVID-19 pandemic and associated responses are having important dis-
tributional and generational effects that amplify pre-existing social inequalities [331]. Concerningly,
many social effects happen at the local level and are invisible due to measurement mishaps and a lack
of sound data. Despite the lack of evidence, it appears that the pandemic has exacerbated important
social issues such as poverty, food insecurity [332], and violence and crimes. Furthermore, the COVID-
19 pandemic affected social care. For example, grandparents had to be protected and could not pro-
vide the childcare they usually do, or alternatively they could not be supported by their children. This
emphasize how resilience is not only about self-care but also about community engagement [333,
334]. In many countries, voluntary action and mutual aid have been stepped up for example for food
shopping or emotional support [335, 336]. These expressions of solidarity are an essential source of
collective resilience [133].
While the direct health impact of the COVID-19 pandemic is more evident for the elderly, the social
impacts of the containment responses are also felt among children and adolescents [337-339]. During
the spring of 2020, the first wave of the COVID 19 pandemic strongly impacted education as schools

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were closed in most parts of the world preventing 1.6 billion schoolchildren and students from attend-
ing school for several months [340, 341]. As of January 2021, schools remain shut in many countries
[342]. A shift to online teaching has been the main source of resilience to school closures. However,
with multiple people in the same household working remotely, Internet capacities were pushed to
their limits making reliable broadband connections a necessity. Critical gaps were further observed in
the quality of online education [343]. With children at home during the lockdown, families needed to
adapt quickly. Adaptation came at the price of an exacerbation of gender inequalities with women
bearing the brunt of the work related to children being out of school [344-346]. In many regions, es-
pecially in low and middle-income countries, schools compensate for societal shortcomings by provid-
ing free school meals and safeguarding children from forced labour and maltreatment [347]. Children
living in more vulnerable environment are more at risk of psychosocial issues following school closure
[348]. The reason is that child resilience is influenced by relationships with caring adults and the wider
educational and social environment [349]. School closures have accordingly exacerbated the eco-
nomic inequalities between rich and poor. In the end, the major concern is that the COVID-19 pan-
demic is putting the future of children at risk [350]. The ongoing crisis in children’s rights might affect
many aspects of society in the future [351].
The COVID-19 pandemic is strongly impacting the functioning of democratic institutions including the
preponderant role of the legislative bodies, representative government, the protection of fundamen-
tal rights, checks and balance on governments, fair administration, and participatory engagement of
the public [352, 353]. Furthermore, the current pandemic is exposing tensions between different hu-
man rights. On the one hand, the state has a duty to protect human life. In fact, while the crisis ampli-
fies inequalities, the pandemic has highlighted the importance of economic, social, and cultural rights
to foster resilience. On the other hand, the measures taken to protect these rights have strongly
clashed with the upholding of civil and political rights [354]. These include the freedom of movement,
the right to demonstrate, and the right to privacy. Fundamentally, the effects of the COVID-19 pan-
demic on human rights disproportionately affected those who do not have a voice.
From a global perspective, the COVID-19 pandemic is evidently impacting global human development
and exacerbating inequalities both within and between countries. Strikingly, the pandemic has ham-
pered efforts to alleviate poverty [355, 356]. Indeed, the World Bank has estimated that 1.4% of the
world population may fall in extreme poverty, hitting middle-income countries especially hard [357].
Poor people living in urban areas in sub-Saharan Africa have already been hit strongly by lockdowns
[358]. In fragile and conflict-ridden countries, disruptions of the humanitarian chain in conflict ridden
areas threaten the survival of children and other vulnerable populations [359, 360]. With an expected
significant increase in the student drop-out rate, the current learning crisis could result in a waste of
human capital and a global generational catastrophe if no further action is taken [341, 361]. Effects
on the youth are likely to be amplified by the burden of austerity.
The impact of the COVID-19 pandemic on migration includes limited access to healthcare and precar-
ious living conditions. With immigration system paralysed, mobility restrictions prevent migrants from
traveling, resulting in labour shortages. Migrants are also at a higher risk of being discriminated
against. The reduction of remittance can deprive households from critical income [362]. Furthermore,
“refugee camps are some of the most densely populated places in the world and residents may not be
able to leave, choose where to go or socially distance themselves” [363]. Overcrowding and a lack of
appropriate infrastructure create the conditions for COVID-19 to disseminate [364, 365]. Overall, the
social costs are leading to a human development crisis in which “inequalities in human development
represent a lack of capabilities for a large part of the population” [117].

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3.4 Environmental
The COVID-19 pandemic had an impact on the environment at both local and national levels. Ecologi-
cal resilience is defined as “a measure of the persistence of systems and of their ability to absorb
change and disturbance and still maintain the same relationships between populations or state varia-
bles” [366]. Because human actions and nature are closely intertwined, a more relevant definition
regarding environmental resilience to the COVID-19 pandemic is the one of social ecological resilience
which has been defined as “the capacity to adapt or transform in the face of change in social-ecological
systems, particularly unexpected change, in ways that continue to support human well-being” [161].
With a reduction of economic activities, (mega)-cities experienced a drastic but not lasting reduction
in pollution [367, 368]. Moreover, the COVID-19 pandemic has been an opportunity to accelerate
some pre-existing trends. As the crisis is testing the resilience of cities to an unprecedented level [369,
370], many local governments prioritised support for the greener economy including measures to pro-
mote cleaner transportation [371]. A concrete example is the development and promotion of bicycle
lanes in urban areas [372, 373]. On the negative side, the pandemic resulted in an increase in certain
waste-related emissions, for example those associated with the production and disposal of personal
protective equipment [374-376]. Recent findings also suggest that food waste increased at the house-
hold scale but was only transitory [377, 378]. It also led to an increased extraction of natural resources,
which is accompanied by deforestation and a reduction of environmental efforts [379].
Moreover, agriculture and food systems have been impacted by the COVID-19 pandemic [380, 381].
For the consumer, lockdowns both impacted the purchasing power and production costs and resulted
in increased food insecurity [382-384]. As some countries also restricted exports of important staple
foods [380], concerns about food security mounted for food-import dependent regions [385-387]. In
terms of food production, it has been maintained in most parts of the world but the COVID-19 pan-
demic tested the resilience of globally interconnected food systems, especially in vulnerable contexts
[388-390]. First, impediments to and delays of food trade and supply chains resulted from public
health restrictions. Second, several high-income countries experienced difficulties with regards to the
availability of seasonal workers for labour-intensive crops (e.g. fruits and vegetables) [391]. In some
cases, primary agriculture production was lost and food prices went down [392, 393]. Commercial
production was particularly affected in some countries [394]. Several sources of food systems resili-
ence have been identified in the literature. With the increase of extra-procurement from consumers
[395], some have argued that the buffering capacity of supermarkets played an important role in main-
taining the food supply [391]. Others have stressed the increasing role of information technologies for
the procurement of food [396-398]. In South East Asia, rural communities were essential to absorb
the return of migrants and increase food production at the household level [399]. The COVID-19 pan-
demic also re-emphasised the importance of home gardening and urban agriculture as a way to
strengthen local food production and create resilience to shock affecting food production [400].
The global impact of the COVID-19 pandemic on the environment is difficult to assess. The drop in
international tourism alleviated environmental pressure on touristic places [401]. Blanket lockdowns
led to a reduction of global daily emissions of CO2 [402]. A study estimated that from January to June
2020 global CO2 emissions were reduced by 8.8% compared to same period in 2019 [403]. The positive
global environmental impact of the pandemic was limited given the current trends towards climate
change. Overall, the COVID-19 pandemic calls into question the place of humankind in nature and the
collective capacity and moral obligation to address global environmental change. Historical evidence
of the expansions and collapse of civilisations suggests that when environmental problems overlap
with diseases, catastrophic impacts on society can ensue [404]. Human civilisation has never sustained

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so many people on the planet. With an unsustainable global production system [405], the space be-
tween the inner boundary of our social foundation and the outer boundary of our ecological ceiling is
becoming thinner [406, 407]. This in turn lowers the resilience of human civilisation to systemic shocks
such as the COVID-19 pandemic.
4 Governing for resilience
The COVID-19 pandemic and its wide-ranging societal impacts serve as a clarion call for a deeper un-
derstanding about how to effectively respond to and govern during major public health emergencies.
Evaluation of responses at the national level has started to attract attention [408-412]. Countries with
better governance have been associated with a shorter outbreak period during the first wave [413].
However, there is a lack of understanding regarding what good governance means during a pandemic.
As swift and bold action is essential to tame an infectious diseases outbreak, it appears that the sweep-
ing powers in combination with widespread citizen surveillance which are both associated with au-
thoritarian regimes gave these regimes an edge when it came to addressing the COVID-19 pandemic.
By contrast, the institutional constraints associated with democracies can prevent a timely and effec-
tive response despite the declaration of a state of emergency. However, the response in New Zealand,
Australia, Norway and Taiwan so far suggests that swift action is also possible within the remit of
democratic regimes [414]. Furthermore, there is not a uniform pattern of response associated with
authoritarianism [128, 415].
Our understanding of the condition under which governance regimes are resilient to shocks is limited.
From a complexity lens, regimes that favour mutual gain are likely to exhibit high fitness to face a
shock in the sense that they promote self-organisation, innovation and creativity. These two qualities
are essential for adaptation in a dynamic environment [416]. By contrast, exploitive regimes which
adopt top-down rules or a “survival of the fittest” mentality, can be considered as less resilient. More
specifically, a complexity lens considers that traditional top-down approaches to governance, which
tend to overestimate the level of control that can be achieved, or the exponential costs of achieving
control, are ill-equipped to address large-scale systemic disruptions [4, 181, 417-419] (Table 3 sum-
marises some important challenges associated with the governance of complex systems). In other
words, failure to appreciate the nature of complex systems can have major and long-lasting conse-
quences [420]. For a challenge such as the COVID-19 pandemic, the main risk is triggering destabilising
cascades of events with far more destructive power than the impact of the pandemic on population
health. The risk of such a destabilising cascade can be increased by the occurrence of multi-hazards
[421, 422].
Table 3. Challenges in governing complex systems
Stage of the
policy process
Concept
Implication for governance and policy
Problem
identification
Complex causality
Policies often fail because they do not reckon with complex causality. Policy
efforts focus on symptoms while the root causes are left unaddressed.
Entanglement and
bounded rationality
Difficulty to achieve a consensus on what is the problem and how it should
be addressed [423]. In addition, limitation of knowledge, information imper-
fection and time constraints lead to sub-optimal decision-making [424]
Embeddedness
Telecoupling makes it impossible to address needs for governance effectively
on a local or regional basis. Complex systems cannot be managed at a single
scale [164]. They require an understanding of drivers at local, national and
global levels.
Policy design
Non-linear effects
Depending on the state of the system and its vulnerabilities, the same action
can have varying effects. In some cases, a small perturbation can trigger large-
scale events while massive efforts can be fruitless.

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Unintended
consequences
A “We can never do merely one thing” approach [425] implies that actions
have always unintended effects. Sometimes theses unintended conse-
quences become the major effect of a policy [426].
Policy resistance and
lock-in
Policy resistance is “the tendency for interventions to be defeated by the sys-
tem’s response to the intervention itself” [427].
Maintaining
effects over time
The strength of
attractors
Complex systems tend to counteract external input and return to the initial
state.
Adaptation
Social agents adapt to policies and goals. For example, when a measure be-
comes a target, it might cease to be an appropriate measure.
Diminishing returns
Initial efforts lead to success but more input does not necessarily result in
more output.
Co-evolution
Coevolution designates the mutual influence that interconnected agents
exert on each other when adapting to their environment.
The analysis of the systemic effects and drivers of resilience in different systems at different social
scales and governance levels suggests that resilience to the COVID-19 pandemic depends on: 1) pre-
existing conditions and vulnerabilities in different systems, 2) the nature of the shock and how it over-
loads and/or reduces systems’ capacities, 3) cascading effects in globally interconnected systems, and
4) actions taken by a range of agents including their capacities and willingness to act (Figure 8). Max-
imising the fit between the governance systems, the nature and severity of the multifaceted effects
of COVID-19, and specific national strengths and vulnerabilities is critical for effective responses. As
SARS-COV 2 are complex systems like other viruses[428], human behaviour affects the evolutionary
pathway of the virus. Maximising the institutional fit between the issue to be governed and the gov-
ernance system is thus a dynamic process. Nimble governance is in turn critical to steer coevolutionary
dynamics toward desirable outcomes[429] [430]. Overall, the review of systemic effects and resilience
in different systems confirms the importance of governments regarding the capacity to adopt public
health and social measures to mitigate the effects of the crisis. However, the different expressions of
the wider capacity to cope, adapt, and transform demonstrate that societal resilience is not primarily
driven by governments, but results from the combination of actions at all scales of social organisation.
Figure 8. A roadmap for assessing the systemic effects and drivers of resilience to the COVID-19 pandemic. The
figure was derived using a template from https://slidesgo.com/
This whole of society approach to resilience suggests that a governance approach that acknowledges
and harnesses complexity is vital for improving responses to the COVID-19 pandemic in open societies.
Overall, the capacity of the state to adopt measures to cope with the situation pertains to what has

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been called ‘mode 1 governance’ [431]. This corresponds to the traditional way to legislate and to
address an issue and implies hard law and sanction-based regulations emanating from traditional in-
stitutions. While, in the short-term, it is critical for governments to respond to immediate needs, such
as supporting the most affected people and activities, a longer-term approach that accounts for sys-
temic disruptions is needed [432]. This approach requires the elaboration of governance mechanisms
and policies that foster resilience. The section below first identifies principles to address the current
governance crisis resulting from the COVID-19 pandemic. A second section focuses on policies to
strengthen resilience to future health crises. Finally, the paper argues that building resilient societies
in the Anthropocene depends on an integrated approach across the four systems [433].
4.1 Resilience principles for the governance of the COVID-19 pandemic
The growing literature on resilience has identified several principles for the governance of social eco-
logical systems [434, 435]. Drawing on these principles and the broader literature on the governance
of complex challenges [159, 431, 436, 437], this paper identifies five key principles to foster resilience
to the COVID-19 pandemic (summarised in Figure 9): 1) encourage a whole of society response
through participation and deliberation, 2) improve communication and complexity literacy to build
awareness and understanding, 3) promote coordination and interplay management to foster policy
coherence, 4) design interdisciplinary learning systems at the science policy interface and 5) foster
polycentricity to protect the distribution and balance of power. These principles, which aim to increase
the capacities to cope, adapt and transform of governance’s actors, are relevant at the local and na-
tional governance levels. They will also be critical for renewing the kind of international multilateral-
ism that is needed to address this crisis. There is a fundamental tension between the dual role of
institutions as providers of stability versus flexibility [438].
Figure 9. An agenda of resilience principles for the governance of the COVID-19 pandemic. The figure was de-
rived using a template from https://slidesgo.com/

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4.1.1 Principle 1 - Encourage a whole of society response through participation and deliberation
The proactive engagement of relevant stakeholders in governance can enhance resilience. Groups and
diverse teams are better at solving complex problems [439, 440]. This means that an effective re-
sponse to COVID-19 should be centred on citizens, public and private organisations, and communities.
Wider consultation, debate, deliberation, and participation in decision-making and implementation of
the measures can improve legitimacy, accountability, and adherence. Information and communication
technologies can enhance collective intelligence [441]. While many decisions that need to be taken to
address a pandemic are time-sensitive, consultation of stakeholders is often possible under time con-
straints [175]. As trust is central to the social contract, a multipronged transdisciplinary approach is
essential for building trust among public health authorities, the public, and businesses [442]. Local and
national governments should provide the principles for the response while creating mechanisms for
community-based engagement and co-designed solutions [443]. Social norms may play an important
role regarding the adherence to the governmental public health and social measures [133, 444], but
excessive moralisation and paternalism associated with denunciation and shaming can also have det-
rimental effects on the social fabric of society [445, 446]. Moreover, community-based initiatives that
foster resilience to the COVID-19 pandemic should be given more attention [447, 448].
4.1.2 Principle 2 - Improve communication and complexity literacy to build awareness and under-
standing
Both an appropriate narrative and a communication strategy are critical in times of crisis [449]. This
calls for more transparency about the number of cases, mortality, excess mortality, age distribution,
risk factors and how decisions are made based on the data. Because complex systems are difficult to
predict and even more so to control, more humility from politicians, health experts and business lead-
ers is needed. In addition, a complexity lens can help policymakers and the public to better grasp the
behaviour of complex social systems including sudden and unpredictable disruptions caused by infec-
tious diseases with explosive potential [450, 451]. As complex systems often exhibit power-laws,
namely that few events account for most of the effects [452], an improved awareness of the dispro-
portionate effects of a small subset of events can inform the prioritisation of resources. This in turn
can help build capacities for adaptive thinking and favour more integrated strategies to tackle the
COVID-19 pandemic. Growing awareness about the behaviour of complex systems requires multi-
modal information campaigns using traditional and social media. Mass media, education, arts and in-
fluencers can harness the power of social networks to shift the worldview from a clockwork universe
to a broader understanding of the place of humans in nature. Educational interventions might foster
adherence to rules in case of events for which the public has no prior experience [453]. From elemen-
tary schools to universities, interdisciplinary education about the origin of life [454, 455], can foster
critical thinking. To make a complexity worldview mainstream, the goal is to train a new generation of
academics, practitioners, and leaders with systems thinking knowledge, skills, and mindsets. Academic
institutions should lead the development of new knowledge while international organisations should
facilitate collective efforts to facilitate the diffusion of resilience thinking about the COVID-19 pan-
demic.
4.1.3 Principle 3 – Promote coordination and interplay management to foster policy coherence
Many actions today can have a dramatic impact tomorrow due to the systemic nature of the crisis. A
delicate balancing-act is required in deploying appropriate action that contains public health threats,
whilst mitigating disruptive consequences of public health measures on other systems. A pervasive
issue in governance includes rigid silos across different regimes. These regimes operate with distinct
norms, values, and priorities, making collaboration challenging. A range of approaches can support
policy coherence [456, 457]. Health impact assessment has been widely promoted as a way to assess
the health impact of policies adopted in other systems [458]. Transposing this approach to a broader

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systemic context means that a first step to address trade-offs is to conduct impact, proportionality
and fairness assessments of measures taken in one system and their impacts on other relevant sys-
tems. Another option is to conduct cross-societal economic analyses such as cost-benefit analyses,
which allow for different types of outcomes in different systems to be quantified and compared. These
assessments in turn will inform policy choices regarding the short and long-term risks and benefits
associated with different options. In any cross-sectoral interaction, ethical issues should be addressed
in a transparent way. Enhancing interfaces, and mechanisms for coordinated response within systems
and across all levels of governance including the public and private sectors can enhance resilience. In
designing mechanisms from simple communication to collaboration, it is critical to reflect on the key
dimensions of accountability between entities in terms of shared information, resources, work and
decision-making [459]. Finally, institutional entrepreneurs who serve as an intermediary between dif-
ferent actors are essential for enhanced network connectivity [460, 461].
4.1.4 Principle 4 - Design interdisciplinary learning systems at the science policy interface
Collective intelligence and diversity are key drivers for adaptation to a new environment [440, 441,
462]. From a complexity perspective, policy failure is a learning opportunity [163]. This emphasises
the need for strong interfaces between science and policy. Many governments adopted similar ap-
proaches with the establishment of a scientific taskforce to provide advice on the COVID-19 pandemic
[222]. This may have supported the coevolution between science and policy [463]. Addressing the
challenges posed by COVID-19 requires further modes and interfaces of collaboration among and be-
tween researchers and policy makers. Problems with adherence to public health measures demon-
strate that sound epidemiology is necessary but not sufficient in addressing the wider drivers of the
COVID-19 pandemic [464]. Embracing collaboration with non-health disciplines, such as social and be-
havioural sciences will therefore be vital. At the local and national levels, there is a need for novel
methods of monitoring and evaluation that can measure countries’ resilience based on a mix of quan-
titative and qualitative metrics. Furthermore, mapping community-based initiatives can provide many
insights into the response to the crisis. Current scientific taskforces that focus on the public health
response should be complemented with the creation of transdisciplinary bodies to consider the effec-
tiveness of the responses from a systemic perspective. An international platform that synthesises
knowledge for action on COVID-19 would strengthen evidence-based policy. Moreover, the study of
pandemics and other macro-shocks to society should become an important interdisciplinary field of
study. This would help improve the necessary systems thinking and coordination needed for a more
holistic approach to governance, preparation, and response. Finally, programs to build research ca-
pacities in low- and middle-income countries can also contribute to building resilience [465].
4.1.5 Principle 5 - Foster polycentricity to protect the distribution and balance of power
Polycentricity, which refers to a governance system with multiple authorities at different levels and/or
in different systems [466, 467], can enhance resilience. Principle 3, i.e. ‘Promote coordination and
interplay management to foster policy coherence’ mainly addresses ‘horizontal polycentricity’ be-
tween systems. Other forms of polycentricity are useful [468]. As the impact of the COVID-19 pan-
demic is territorially differentiated [469], governing for resilience stresses subsidiarity, namely, the
devolution of power to local governments. This can in turn foster participatory resilience [470] (Prin-
ciple 1). However, to reduce the fragmentation of response, subsidiarity should be accompanied by
enhanced mechanisms for vertical polycentricity, i.e. collaboration across levels of governments. A
highly relevant approach is multilevel governance which provides a way for bringing together repre-
sentatives of different levels of governance [469]. Polycentricity also applies beyond national govern-
ments. For example, international collaboration between cities and regions can strengthen coherence
between neighbouring countries and foster multilateral cooperation. Finally, polycentricity is also re-
lated to the balance of power within governments. While an emergency response tends to lead to a

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concentration of power of the executive branch, reinforced procedures are needed to ensure the bal-
ance of power between the executive, judicial and legislative branches, alongside the respect for hu-
man rights and the rule of law. At the international level, preparation to mitigate the potential and
effective violations of human rights should be ramped up. Furthermore, strategies are needed to en-
sure that bouncing back fosters greater protection for all members of any community within the juris-
diction of any state.
4.2 Preventive, reactive, and recovery resilience to build robust systems
Governing for resilience in an era of turbulence stresses the need to reduce shock diffusion and prop-
agation whilst strengthening shock absorbing mechanisms [80]. The key policy principle is to build
robust systems that can prevent, react, and recover from a number of shocks. The related properties
of complex systems that need to be addressed include connectivity, redundancy, diversity, and diffi-
cult-to-change feedback processes [435, 471, 472]. While measures have been implemented to con-
trol the current COVID-19 pandemic, building resilience requires longer term actions that address the
above properties in different systems. Drawing on the definition of resilience in this paper, the next
section examines recovery resilience to the current COVID-19 pandemic as well as preventive and
reactive resilience to future pandemics (figure 10).
Figure 10 Different types of resilience across the pandemic timeframe to build robust systems
4.2.1 Health
With health systems deeply disrupted by the pandemic, recovery resilience is conditional upon the
control of the pandemic. Adaptive management should guide the recovery process [473]. Public health
and social measures provide the foundation for reducing the duration and impact of the pandemic,
but vaccines can be a game changer. The distribution of vaccines poses an enormous logistic and global
justice challenge. In addition, the problem of vaccine hesitancy which has been brewing for a long
time is likely to hamper efforts at tackling the pandemic [474, 475]. Increasing the resilience of im-
munisation systems to vaccine hesitancy requires integration between essential components, innova-
tive interventions and effective communication strategies [476-479]. In addition, recovery resilience
requires restoring the physical and mental health of the population which entails the development of
specific programmes and their integration within existing health systems [480]. Recovery resilience
also encompasses the reactivation of essential health services [481] and the repair of patient provider
relationships. Some health services are particularly at risk of being neglected and must be recognised
[482]. In developing countries, public health activities such as immunisation should be prioritised as

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they provide long-term benefits for public health and human development. Depending on the trajec-
tory of the COVID-19 pandemic, health systems may have to adapt to the continuing use of resources
to address the pandemic.
Building preventive resilience to future pandemics requires capacities to both detect unusual or un-
anticipated events and react quickly when an outbreak with pandemic potential is detected in the first
affected country. This emphasises the critical role of investments for building robust public health
systems [483]. Core national public health capacities that need to be stepped up include surveillance
(laboratory capacities) and responses. Early warning systems could be deployed to monitor for ante-
cedent conditions that are conducive to emergence of infectious diseases [484-486]. A very important
component is clear communication with the World Health Organization headquarters as required by
the International Health Regulations. Another component is a team which can rapidly be dispatched
anywhere in the world to help countries who are lacking capacities or need additional ones. This set
of measures and arrangements are already part of the International Health Regulations. To make them
more effective, efforts should concentrate on more clarity, transparency, and accountability, and a
revised assessment of the core capacities that countries need to develop [487]. Given the level of
interconnectedness, an additional measure might be rapid implementation of air travel restriction
that could be backed up by a global insurance mechanism [488].
The COVID-19 pandemic demonstrates that an emerging pathogen with pandemic potential can go
undetected for weeks or even longer. This means that preventive resilience should be complemented
with strategies for reactive resilience. Accordingly, health systems should be prepared to face disrup-
tions from emerging infectious diseases and other global health threats. Building healthcare resilience
primarily revolves around investing in community-based, inclusive, and equitable health systems [489,
490]. Universal Health Coverage provides the foundations for resilient health systems that can flexibly
respond to a variety of challenges and hardships in an equitable way [491, 492]. Building surge capac-
ity entails allowing some redundancy in our health care systems. Achieving this requires a shift in our
approach to governance and evaluation of healthcare systems from pure economic efficiency to ef-
fectiveness and adaptability. This in turn raises questions regarding competition in healthcare systems
[493]. At the operational level, it is critical to elaborate strategies for the re-organisation of hospitals
in a pandemic scenario and to provide support to healthcare workers [494-496]. To enhance precision
of the public health and healthcare response [497], the development of health technologies including
drugs, diagnostics, and vaccines against global health threats must be supported by innovative funding
mechanisms [498]. The use of information and communication technologies to monitor and control
epidemics should be further evaluated. A proper plan should be in place for communication with the
public [125]. Finally specific attention should also be devoted to different health-related vulnerabili-
ties. The syndemic nature of the pandemic should re-invigorate efforts for health promotion and pre-
ventive medicine to reduce health vulnerabilities such as obesity [499] and to target population with
specific needs [500]. In addition, investments should be made in maternal, neonatal and child health
as this will contribute to reduce vulnerabilities in population health [501].
Strengthening recovery, preventive, and reactive resilience entails a transformation of health systems
[482, 490]. This transformation should be supported by sound and inclusive governance mechanisms
[502]. Participation (Principle 1) of different medical and public health specialisations can be increased
[503]. In terms of complexity literacy (Principle 2), the COVID-19 pandemic is a compelling case for
strengthening health systems’ capacities based on systems thinking [7, 504]. In terms of coordination
and interplay management (Principle 3), assessing trade-offs regarding both action and inaction is a
critical task. The health costs of preparing societies against pandemics amount to the billions of US$
[505], but the COVID-19 pandemic has made obvious that the benefits far outweigh costs. This is even

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more the case as strengthening preparation for pandemics can support the fight against other infec-
tious diseases such as antimicrobial resistance [9, 506]. In addition, global collective action (Principle
3) to support the implementation of the International Health Regulations in different countries will
increase both preventive and reactive resilience. Overall, many aspects of the pandemic of COVID-19
such as transboundary regulations, provision of health supplies and drug/vaccine development will
benefit from collective action. The development of interdisciplinary learning systems (Principle 4) is
critical for developing a better understanding of health resilience. Prospective assessments and meas-
urements of resilience will guide the development of an implementation framework [188, 507]. Law
and ethics further provide a powerful approach to strengthen global health resilience at the national
level and, when based on a multilateral approach, at the international level also [261, 508, 509]. Ulti-
mately, a stronger World Health Organization that is equipped to work with other stakeholders (Prin-
ciple 5) is needed if we are to prevent and prepare to another pandemic [510, 511].
4.2.2 Social
The COVID-19 pandemic has exacerbated social inequalities but the full extent of its effects on social
systems will take time to unfold. Recovery resilience in local social systems critically revolves about
mutual assistance [512], but several processes can be accelerated by sound policies. Critically, recov-
ery from the COVID-19 pandemic will be about the restoration of societal connectedness that has
been severely hindered by public health and social measures to address the COVID-19 pandemic. Ur-
gent action is needed to reaffirm and protect rights of all people. In addition, efforts are needed for
implement programs to support victims of psychological distress. Given the impending impact of the
COVID-19 pandemic on future generations, one of the most critical investment is about education.
Relevant actions include stepping up social support to children and adolescents, recognising schools
as social space for socialisation and collective living, (re-)valuing teaching profession, and developing
access to educational technologies [338, 513]. Investment in education will help build more equal and
inclusive societies [514-516]. Turning the tide on poverty and gender inequalities will require stepping
up social policies. Indeed, economic studies of well-being have established that people do not make
up for the well-being lost through inequality and discrimination [517, 518]. Austerity policies that log-
ically follow fiscal expansion can hinder recovery and reduce preventive and reactive resilience.
Preventive social resilience to pandemics is about reducing the social vulnerabilities associated with
the emergence of infectious diseases. Poverty is not only a risk factor for acquiring infectious diseases
but also a driver of spillover of infectious diseases which is mediated by the consumption of wild ani-
mals and encroachment on wildlife. Poverty alleviation can reduce risky behaviours that leads to the
mixing of domesticated/wildlife animals and humans. Overall, it is critical to better understand the
social context and behaviours that lead to the spillover of emerging infectious diseases from animals
to humans [46]. While social life is by nature conducive to the spread of infectious diseases, preventive
resilience is also about the rapid endorsement of behaviours that allow societies to react quickly when
confronted with an emerging infectious disease with pandemic potential. Population and govern-
ments should be prepared to face other emerging infectious diseases by adopting appropriate
measures. This agenda includes investment for interventions that promote individual resilience [309].
Social resilience fundamentally stems from increasing solidarity both within and between countries in
the view that “an equity lens is essential because existing inequalities mediate the impacts of the crisis
on human development” [117]. The pandemic has clearly revealed social vulnerabilities which can re-
duce resilience to pandemics. Building reactive resilience to pandemics implies strengthening mental
health systems [519]. For example mental health services for young people is underdeveloped in many
countries. Increasing the absorptive and adaptive capacities also entails addressing the social deter-
minants of health that affect the potential of people and make them more vulnerable to the effects

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of large-scale events such as a pandemic. Using a capability approach that stresses the moral signifi-
cance of the freedom of people to choose their own life [520], countries should strengthen the safety
net for all citizens through innovative revenue schemes or other context-appropriate mechanisms.
This will also limit risky behaviour regarding the transmission of future pandemics. Particular attention
should be placed on the principle of non-discrimination in any shape or form.
The three components of social resilience should be supported by governance mechanisms that foster
participation and public deliberation (Principle 1). Social capital, namely “the links, shared values and
understandings in society that enable individuals and groups to trust each other and so work together”
[521], is the main driver of recovery after disaster [512]. Adapting and shaping change also requires
the ability to mobilise social capital [522]. A key measure is the re-allocation of resources through
evolutionary policies [523] and legal frameworks with participatory processes (Principle 1) in place for
the inclusion of citizens, communities, civil society, business entities and other relevant and/or forgot-
ten stakeholders such as the elderly, young people and marginalised minorities. This also suggests that
polycentric systems (Principle 5) can improve the distribution of power among different actors and
favour community engagement. As a foundation of prosperity and political stability, a rights-based
approach that stresses proportionate, necessary, and non-discriminatory governmental response is
vital for supporting social resilience [524].
4.2.3 Economic
Economic recovery for resilience is about creating the conditions for reconstruction, rehabilitation and
restoration. Providing a more stable environment regarding the epidemiologic evolution of the pan-
demic will be a first step toward recovery as many countries have been confronted with several waves.
The role of governments in supporting affected sectors and firms to reduce impacts on economic flows
revolved mainly around the provision of adequate access to funds [525]. So far, many actions under-
taken by governments have followed a short-termism logic: rescuing failing businesses rather than
fostering comprehensive economic recovery fit for the 21st century [526]. An essential priority is to
better operationalise recovery at the business level [527]. Stimulus packages coupled measures than
improve business and consumer confidence provide the backbone for economic recovery. An im-
portant issue is that classical monetary cushions have been exhausted in many high-income countries
and soaring government debt has lowered fiscal capacity [528]. Global economic recovery requires an
expansionary plan which emphasizes new multilateral solutions [529]. For example, a global tax on
systemic risks has been proposed to address low probability yet high impact events such as the COVID-
19 pandemic [419]. As the growing sovereign debt soars, a debt restructuring framework is needed to
reduce the risk of sovereign debt crisis.
In terms of preventive resilience, economic preparedness for pandemics signifies that first each com-
pany has a plan regarding the protection of workers and can shift to remote working when possible.
While economic globalisation influences the emergence and spread of pathogens through travel and
trade, reducing these interactions is not economically desirable. However building preventive resili-
ence to pandemics incurs a better monitoring of risk across borders and strengthening the regulatory
framework regarding trade. For example, a very targeted and potentially effective measure would be
to limit wildlife trade [530]. Moreover, efforts to transition to more sustainable form of agriculture
along with respect for biosecurity measures can curtain the potential for spillover from animals to
humans [531]. A long-term action towards the prevention of pandemic could also include further in-
vestment towards the development of the circular economy to reduce, reuse, and recycle [532-534].
Reactive economic resilience can specifically be “strengthened by policies and institutions that help
mitigate the consequences of severe recessions” [535]. Countercyclical mechanisms through both fis-
cal and monetary policies can foster economic resilience to external shocks [536]. In addition, reactive

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resilience to pandemics entails having the capacity to deal with shocks affecting supply and demand.
As the market is primarily centred around efficiency, it tends to reduce redundancy and spare capacity,
yet these are both useful for building resilience [435]. As recognised after the global financial crisis of
2008, there is also a need to improve our understanding of the vulnerabilities of different economic
sectors to a range of shocks. Risk mitigation strategies have been implemented in the financial sector
but there are still gaps in our understanding of economic vulnerabilities at the firm level, especially
when it comes to an external shock such as a pandemic [537]. Furthermore, attention should be given
to international trade where less concentration of production can increase diversity in supply chains
and in turn reduce susceptibility to shocks. This should cover resilience assessments in supply chains
[538], where “adaptation, digitalization, preparedness, recovery, ripple effect, and sustainability” have
been identified as the main components of the current research agenda [295]. Countries should per-
form vulnerability assessments regarding their dependence on trading partners from a regional per-
spective.
In terms of governance, several principles identified in the previous section will be particularly relevant
to foster economic resilience. Principle 1 about participation is key as affected economic sectors need
to be able to voice their concern regarding the recovery process. Moving our understanding of the
economy as a complex system (Principle 2) provides a more profound way to support economic resil-
ience [539]. This entails changing the narrative regarding prosperity, in particular its current fixation
on the pursuit of exponential economic growth at any societal costs [540, 541]. Finally, the develop-
ment of interdisciplinary learning systems (Principle 4) is crucial as a way to further operationalise
resilience thinking at the economic level where critical gaps regarding the measurement of resilience
hinder our capacity to design effective policies.
4.2.4 Environmental
The pandemic of COVID-19 has had mixed effects on the environment. Essentially, environmental re-
covery resilience is not only about addressing the negative environmental impacts of COVID-19, but
also about exploiting the positive ones such as the reduction of green gas emissions. On the one hand,
negative environmental impacts, on waste for instance, should be curtailed with investments in im-
proved waste management [542]. On the other hand, the COVID-19 pandemic is an opportunity to
consolidate positive side-effects of the reduction of economic activity, especially as their long-term
sustainability is questionable. Drawing on ongoing changes in social norms, efforts should be scaled-
up to counteract the negative impact of transportation by facilitating and improving remote working
conditions and promoting green transportation. Restoring food security can also help to alleviate the
pressure on the environment. This suggests further efforts to decouple food production from environ-
mental degradation [47, 543]. Finally, diversification of production is essential for improving security
while promoting activities that are respectful to the environment [390].
In terms of preventive resilience, “the most effective pandemic prevention at this early stage would
be via measures that target the underlying causes of disease emergence” [46]. Environmental resili-
ence to pandemics is primarily linked to the prevention of zoonoses from wild or domesticated ani-
mals. The COVID-19 pandemic calls for strengthening One Health approaches to identify and monitor
hotspots for emerging infectious diseases. Concrete policies for risk reduction at the source include
better surveillance. Animal health surveillance should notably be strengthened and better integrated
with human health surveillance [544-546]. As the fate of human civilisation cannot be distinguished
from the trajectory of the biosphere, building resilience to pandemics relates to the broader agenda
of environmental resilience and planetary health [50, 547]. A first key area for improvement is the use
and management of natural resources including better energy and other resources’ efficiency. Fourth,
the protection of biodiversity, which underpins human health [548, 549], should be strengthened by

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the adoption of ambitious biodiversity and sustainability targets [550]. Overall, building resilience to
pandemics strongly depends on how we tackle climate change [551, 552].
Reactive environmental resilience revolves around limiting the factors that exacerbate the risk of
transmission. For example limiting air pollution in affected cities can reduce the number and severity
of infections. As the weather seems to play an important role, it has been suggested that short-term
measures should be considered when weather conditions may drive COVID-19 morbidity and mortal-
ity [553]. Limiting indoor air pollution which is a particularly rampant problem in many developing
countries could also help address a pandemic driven by a pathogen with a respiratory tropism. It has
been suggested that several measures could be taken at the household and working place levels to
reduce indoor air pollution [554]. Finally, improving the built-in environment including the design of
indoor spaces and city planning can also help make cities more resilient to pandemics [555-559].
The relevant principles for building environmental resilience to pandemics includes the development
of learning systems (Principle 4) that allows a better understanding of the relationship between social
and ecological systems. Improving communication and literacy (Principle 2) about complexity is also
key for the public to gain a better understanding of the relationship between humans and nature.
Because of the very large number of stakeholders involved in food systems, improving environmental
resilience can only be made through transdisciplinary processes that engage a wide range of actors
including farmers, businesses, and members of the community.
4.3 Systems integration for transformation towards resilience and sustainability
The four resilience systems – health, economic, social, and environmental – are interconnected in
several ways [560]. In the short-term, reacting and adapting to a shock in one system might result in
a loss of resilience in other systems. While this might be desirable in the short-term, it is critical to
avoid a reduction of resilience in other systems in the long term. Building health resilience while dis-
carding environmental resilience will fundamentally not address the drivers of emerging infectious
diseases. Prevention of future health crises will require addressing the drivers and risks of emergence
of infectious diseases [561]. In addition, health resilience is further related to economic and social
resilience as both innovation for and access to health technologies are vital for addressing pandemic
risks. Moreover, building health resilience through preparedness can protect the economy from sud-
den disruptions such as the COVID-19 pandemic [562]. Healthy people are also crucial for a strong
economy [490]. Overall, these different linkages signal that ultimately global health security cannot
be separated from solidarity and sustainability [563].
The links between systems do not flow exclusively from health resilience to other systems. Other sys-
tems contribute to health resilience. Social resilience is closely entwined with health and economic
resilience, as economic crises and austerity amplify distributional effects and have long term conse-
quences on social conditions and public health [564-567]. Economic and social resilience are two sides
of the same coin [266]. Supporting economic resilience for a quick recovery might prioritise the cur-
rent model of economic growth and fails to address the broader environmental change that led to the
COVID-19 pandemic. By contrast, investment to accelerate the transition to a green economy can fos-
ter both economic and environmental resilience to pandemics for the longer term. As such, efforts
should be made to reconnect economic indicators with societal needs and effective economic outputs.
Emphasis should be on decoupling development and growth to focus on well-being [568]. In addition
to investments in education, training and research and development, key areas for interventions to
support recovery while fighting climate change may include increasing building energy efficiency, la-
bour-intensive clean infrastructure projects, pricing carbon scheme in association with lower labour
taxation, and reforestation and other ecosystem restoration programmes [526, 569]. It has been ar-
gued that a non-conventional mechanism such as a monetary stimulus could finance decarbonisation

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programmes [570]. Building environmental resilience to pandemics implies reducing the disruptions
of nature by humans’ actions in a way that does not compromise the social and economic foundations
of society. Overall, the assessment of health resilience in relation to the social, environmental, and
economic components of sustainable development emphasises a systemic approach to build resili-
ence (Figure 10). Supported by the governance principles identified in section 4.1, this systemic ap-
proach should foster preventive, reactive, and recovery resilience within and across the four systems.
Figure 11. A systems-wide global transformation plan: moving from fragmented resilience to comprehensive
resilience to future pandemics across the health, social, economic, and environmental systems
Fostering systems integration for resilience and sustainability will be key to face complex challenges
in the Anthropocene [571]. This ambitious agenda requires efforts at both the research and policy
levels and between them. This calls for multi-stakeholder collaborations to work across the four key
systems discussed in this paper. At the research level, a first priority is to generate more empirical
evidence about resilience to pandemics, particularly in relation to resilience assessment/management
[572, 573]. There is a need to identify good practices in the affected systems (e.g. health) and settings
(e.g. hospitals) to learn or draw upon (Table 4 provides a number of key dimensions for further stud-
ying resilience). A second priority is to improve our interventions portfolio [574] and to better under-
stand how systems can be designed to reduce the risk of cascading failure [575]. Research should aim
to evaluate the effectiveness and implementation of complex interventions in different systems [576].
A third priority is to better understand how the capacities to cope, adapt, and transform can be em-
bedded within governance in organisations or political systems [577, 578]. While it has been argued
that a shift towards the prevention of pandemics would be transformative [531], key research topics
include the evaluation of cost-effectiveness of measures that build preventive resilience versus reac-
tive and recovery resilience. A fourth priority relates to the conditions under which resilience is con-
vergent with or divergent from sustainable development. Better quantification of resilience will help
to assess key trade-offs between efficiency, sustainability, and resilience [432]. Efforts should focus
on assessing different scenarios and pathways for sustainability transformations to unfold [579]. A
fifth priority is to improve our understanding about the conditions under which conventional govern-
ance arrangements are inadequate to effectively manage governance of complex systems [431]. This
also raises questions regarding who benefits from resilience building and what are the power dynam-
ics at play. Drawing on the growing insights from team science [580, 581], the priorities identified

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above requires unprecedented investments in interdisciplinary and collaborative research [582]. The
overall research agenda on resilience to pandemics also relates to other research agenda such as earth
system governance [583, 584]. There is an immediate need for a global commission to analyse lessons
from the COVID-19 pandemic through the lens of complex systems.
Table 4. Relevant analytical dimensions for building resilience through policymaking and governance
Variable
Values or sub-variables
Comments
Systems
Health, social, economic,
environmental
Comprehensive resilience is achieved across the health and
three interdependent systems of sustainable development.
Social organisation
scales
Individual, household,
organisation, community,
society
Different societal agents across the social organisation scales
are relevant for building resilience.
Governance levels
Sub-national, national,
regional, international
Governance levels should be considered in conjunction with
the social organisation scales.
Temporal action
scale
Pre (preventive), peri (reactive),
post (recovery)
Strategies to build resilience can be related to their
temporality regarding a shock. This extends the definition of
resilience beyond reactive strategies.
Resilience
capacities
Cope, adapt, transform
Described in terms of different capacities to face shocks.
There might be trade-offs between developing these different
capacities.
Principles to build
systems’ robustness
Diversity and redundancy,
modularity and connectivity,
slow feedbacks
Originating from ecological thinking that makes systems
resilient to shocks.
Governance
principles
Participation, communication,
coordination, learning,
polycentricity
These principles are especially relevant to building resilience
in democratic societies.
At the policy level, the current pandemic is shaping our imagining of the adjacent possible with nu-
merous calls for a ‘great reset’ or for ‘building back better’. In balance with efficiency and sustainability
goals, resilience should become a key priority of policymaking based on multilateral approaches to
decision making at all governance scales. Considering resilience in the four systems as totally inter-
linked will support actions to prevent, react to and recover from pandemics. As discussed in the pre-
vious section about governance principles, the adoption of a complexity lens in policymaking and gov-
ernance can foster new approaches, mechanisms, and institutions, based on the development of
shared understanding, open communication, stakeholder engagement, coherence in decision making,
maximisation of synergies across systems and goals, and the management of externalities [585-587].
As a systemic framework relevant to all countries to relate knowledge and policy goals from different
perspectives [588-590], the 2020 inclusive sustainable development agenda provides the most direct
and useful policy foundation for recovery, adaptation, and transformation [591]. However, the current
pandemic is also putting the Sustainable Development Goals to test, stressing the need for further
commitments [592] and a re-assessment of priorities after COVID-19 [568]. In some regions, commit-
ments were made prior to the COVID-19 pandemic. For example, in 2019, the European Union
adopted a Green New Deal for decarbonisation by 2050 [593]. Furthermore, calls have been made for
a Green New Deal that would foster economic recovery while accelerating the sustainability transition
[594], but little coordinated action has taken place at the global level as of January 2021. To overcome
lock-in, the critical action is for people at all levels to exploit the socioeconomic tipping-point to trigger
change [595-599] and develop new modes of governance [94, 431]. Beyond a global recovery plan,
what is needed is a global transformation plan supported by both down and bottom up approaches.
Now is the time for human societies to harness the self-organizing power of complexity to shape effi-
cient yet inclusive, sustainable, and resilient societies.

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