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ChopraM, KasperT. BMJ Global Health 2021;6:e007237. doi:10.1136/bmjgh-2021-007237
Health systems resilience and
preparedness: critical displacements
and disruption
Mickey Chopra, Toby Kasper
Commentary
To cite: ChopraM, KasperT.
Health systems resilience
and preparedness: critical
displacements and
disruption. BMJ Global Health
2021;6:e007237. doi:10.1136/
bmjgh-2021-007237
Handling editor Stephanie M
Topp
Received 23 August 2021
Accepted 30 August 2021
World Bank Group, Washington,
District of Columbia, USA
Correspondence to
Dr Mickey Chopra;
mchopra@ worldbank. org
© Author(s) (or their
employer(s)) 2021. Re- use
permitted under CC BY- NC. No
commercial re- use. See rights
and permissions. Published by
BMJ.
INTRODUCTION
COVID- 19 has highlighted the importance of
resilient health systems. The concept of resil-
ience has been evolving, with attributes such
as feedback loops, learning capacity, adapt-
able management, flexibility and openness to
systemic change take on greater importance
from the earlier emphasis upon more fixed
attributes such as numbers of laboratories,
surveillance systems, etc1–3
However, a recent review notes the missing
role of power relations and actors in such
studies.4 That this is so prevalent suggests a
systematic oversight. Here, we identify three
‘displacements’ in many approaches to resil-
ience and how this can radically change the
approach.
DISPLACEMENT OF POLITICAL ECONOMY
In the face of perpetual and multiple threats,
the emphasis is on the resourcefulness and
ingenuities of individuals and communities
that refuse to surrender to all forms of endan-
germent. This emphasis on resourcefulness
and ingenuity is part of the wider assemblage
of ‘disaster management’ that focuses on the
importance of being prepared and resilient
against shocks such as climate change and,
now, pandemics.5
Earlier these shocks were understood to be
an act of nature or divinity, whereas they are
now understood to be the almost inevitable
side effect of development and modern life.
The corollary of this is that individuals and
communities need to be guided through
this complex world by technical experts,
who can deploy scientific methods to dissect
and understand problems.6 Subsequently,
the focus is on the expert measurement of
‘ontologies of vulnerability’—deficits in indi-
viduals, communities or systems. Prescrip-
tions to ‘fill’ these deficits invariably focus on
public–private partnerships, civil society and
individual efforts.7 The underlying political
economy—the wider interaction of politics
and the economy—is often left unexamined.
The latest manifestation of this impulse is
the concept of ‘one health’. This rightly high-
lights the interconnections between humans,
animals and their shared environment but the
focus on the pathogen, hosts and immediate
environment displaces key political economy
determinants such as global capital flows that
increasing shape land ownership and use and
agricultural practices. The rapidly changing
rural landscapes and livelihoods, for example,
even in the poorest periphery of the world,
are now shaped by the investment decisions
of global mining, agricultural, transport and
retail industries and finance speculators made
in a few global centres.8
DISPLACEMENT OF POLITICS
COVID- 19, along with Ebola, HIV and avian
influenza, is presented as a further sign of
the universal, catastrophic power of external
natural forces. Such a framing enables the
Summary
►The COVID- 19 pandemic has presented an oppor-
tunity to reconsider health systems from the per-
spective of resilience and pandemic prevention and
preparedness.
►Lessons from previous epidemics along with in-
sights from other elds have not only already given
rise to a burgeoning literature on elements of such
systems but have also systematically underplayed
key elements such as power.
►We argue that the current framing of the issues is
displacing several more fundamental drivers of poor
systems performance and population outcomes
such as political economy, politics and history.
►The incorporation of a broader framing of the issues
leads to a very different approach towards analysing
the causes and formulating the response to build
more resilient and just health systems.
on September 30, 2021 by guest. Protected by copyright.http://gh.bmj.com/BMJ Glob Health: first published as 10.1136/bmjgh-2021-007237 on 29 September 2021. Downloaded from
2ChopraM, KasperT. BMJ Global Health 2021;6:e007237. doi:10.1136/bmjgh-2021-007237
BMJ Global Health
displacement of the politics in at least three ways: First,
there is no clear privileged subject for change, the enemy
is often externalised and objectified. Requiring everyone
to act equally against ‘natural disasters’ blurs both the
political origins of causes (eg, uneven distribution of
power relations, networks of control and influence) and
those social groups or movements best placed to combat
them. Second, the fact that all geographies and groups are
affected enables a universalistic rhetoric to be deployed,
but this obscures the fact that politics shapes who is most
affected. This has been clearly illustrated by the very
different impacts of COVID- 19 on poorer, marginalised
populations9 but where their specific experience and
differential claims have often been subsumed by the ‘we
are in it all together’ discourse.10 Third, the impending
catastrophes of future outbreaks lead to a sense that if we
refrain from acting immediately, our world’s future is in
grave danger—the experts need to start acting without
waiting for the messiness of regular politics.11
This fits well with the recent shift of global agencies
away from often frustrated attempts to build state and
institutional capacity towards governance approaches.
Greater attention is now given to specific ‘policies’ rather
than ‘politics’ and to ‘populations’ rather than collec-
tive political subjects such as ‘citizens’. All bolstered by a
reliance upon global experts to measure progress rather
than engaging and strengthening local measurement
and accountability systems.12
DISPLACEMENT OF HISTORY
The long history of the medical establishment’s role
in advancing racist, sexist and classist ideologies has
received renewed attention as part of efforts to under-
stand vaccine hesitancy.13 Particularly blatant examples
such as the Tuskegee experiments on black men or the
British military’s testing of the effects of mustard gas on
Indian soldiers are now widely acknowledged. But the
narrow focus on a few egregious episodes contributes
to burying other histories and with it a more radical
understanding of the current situation.
One example is the genealogy of epidemiology and
infection control tools (e.g., mapping, quarantining of
contagion) and language (e.g., reconnaissance, inva-
sion, combat) that were originally mobilised by colonial
administrations to both control rebellion and obscure
its own motives, agency and legitimacy. More recent
analysis traces how these tropes have been reinvented
and repurposed by different regimes up to the present
day.14 15 Dismissing local criticism of epidemiology and
public health measures as ‘unscientific’ ignores the
complicated histories that many marginalised groups
have with these concepts.16
The historical shaping of current social relations
by forces that are still dominant is another example.
The main structural drivers of the differential impact
of COVID- 19 on marginalised rural populations in the
American west, for example, were generated a century
ago, when the US Congress rejected a proposal for a
communitarian, decentralised, river- basin- confined
settlement system for the region and instead supported
large- scale corporate interests pursuing the construc-
tion of dams and other mega- water projects.17 This,
in turn, relied on the formation of institutions such
as large- scale agribusiness and an oppressed landless
agrarian workforce (now largely made up of immi-
grants) for its perpetuation,18 groups that have suffered
disproportionately from COVID- 19.19
DISPLACING THE DISPLACEMENTS
Without addressing these displacements risks a health
resilience and preparedness agenda with a veneer of
progressiveness but which closes down more radical
critiques by consolidating around expert, technocratic
power, by generating a shrunken, non- conflictual
critique of social power structures, and by focusing
the scope of proposed solutions heavily on the indi-
vidual. Counterintuitively, here we suggest two further
displacements that could ‘recentre’ critical perspec-
tives: displacing an ontology of vulnerability with an
ontology of oppression and displacing the domination
of experts with a greater plurality of knowledge and
voices.
The pandemic reminds us that the processes for the
persistence of inequities reside not only just in formal
relationships but also in the everyday practices such
as bureaucratic administration or workplace safety.
Mapping, in specific settings, how the pandemic is
reenforcing what Young calls the ‘five faces of oppres-
sion’—exploitation of labour (workplace and living
space), marginalisation of social groups by virtue of
their identity, powerlessness (lack of resources to act
meaningfully in political life), cultural imperialism
and violence (including within the family)20—is one
starting point for an approach that draws attention to
the base structures and processes.21
This is one thread that can tie the technical with
broader progressive social movements. Technical experts
and agencies need to work with those most affected in a
fully democratic process of understanding the structures
and processes that have replicated and amplified different
forms of oppression from ‘up close, as internal to the
collectivities and sensitive to human actions, to which
they react swiftly’ (Latour).22 A disruptive agenda—one
that prevents shocks as much as dealing with them.
Sixty years ago a new US President made a call to arms
to the post- war generation. Perhaps as a community of
scientists, policy- makers and technocrats, we need to
make a similar commitment and ask not what we can
do to build back better from COVID- 19 but rather ask
what COVID- 19 can do to amplify the voices, power and
leadership of those that have lost the most.
Contributors Both authors conceptualised and wrote the article.
Funding The authors have not declared a specic grant for this research from any
funding agency in the public, commercial or not- for- prot sectors.
on September 30, 2021 by guest. Protected by copyright.http://gh.bmj.com/BMJ Glob Health: first published as 10.1136/bmjgh-2021-007237 on 29 September 2021. Downloaded from
ChopraM, KasperT. BMJ Global Health 2021;6:e007237. doi:10.1136/bmjgh-2021-007237 3
BMJ Global Health
Competing interests None declared.
Patient consent for publication Not applicable.
Provenance and peer review Not commissioned; internally peer reviewed.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non- commercially,
and license their derivative works on different terms, provided the original work is
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REFERENCES
1 Turenne CP, Gautier L, Degroote S, etal. Conceptual analysis
of health systems resilience: a scoping review. Soc Sci Med
2019;232:168–80.
2 Nuzzo JB, Meyer D, Snyder M, etal. What makes health systems
resilient against infectious disease outbreaks and natural hazards?
results from a scoping review. BMC Public Health 2019;19:1310.
3 Kruk ME, Ling EJ, Bitton A, etal. Building resilient health systems: a
proposal for a resilience index. BMJ 2017;357:j2323.
4 Topp SM. Power and politics: the case for linking resilience to health
system governance. BMJ Glob Health 2020;5:e002891.
5 Pugh J. Resilience, complexity and post- liberalism. Area
2014;46:313–9.
6 Giddens A. Modernity and Self- identity - Self and Society in the late
Modern Age. Stanford USA: Stanford University Press, 1991.
7 Evans B, Reid J. Exhausted by resilience: response to the
commentaries. Resilience 2015;3:154–9.
8 Wallace RG, Bergmann L, Kock R, etal. The dawn of structural one
health: a new science tracking disease emergence along circuits of
capital. Soc Sci Med 2015;129:68–77.
9 O'Dowd A. Covid- 19: people in most deprived areas of England and
Wales twice as likely to die. BMJ 2020;369:m2389.
10 Sobande F. ‘We’re all in this together’: Commodied notions of
connection, care and community in brand responses to COVID- 19.
Eur J Cult Stud 2020;23:1033–7.
11 Swyngedouw E. ‘The Non- Political Politics of Climate Change.
ACME 2013;12:1–8.
12 Adams V, ed. Metrics: What Counts in Global Health. Duke University
Press, 2017.
13 Lin C, Tu P, Beitsch LM. Condence and receptivity for COVID- 19
vaccines: a rapid systematic review. Vaccines 2021;9:16.
14 Kolb AFR. Epidemic Empire: colonialism, contagion, and terror,
1817–2020. Chicago: University of Chicago Press, 2021.
15 Sriram V, Keshri VR, Kumbhar K. The impact of colonial- era policies
on health workforce regulation in India: lessons for contemporary
reform. Hum Resour Health 2021;19:100.
16 Richardson ET. On the coloniality of global public Heath. Med
Anthropol 2018;6:101–18. doi:10.17157/mat.6.4.761
17 Stroshane T. Rivers of Empire: water, aridity, and the growth of the
American West by Donald Worster. Berkeley Plan J 1988;3.
18 Harvey D. The nature of environment: the Dialectics of social and
environmental change socialist register 1993;3.
19 Maxmen A. Inequality’s deadly toll Nature, 2021. Available: https://
www. nature. com/ articles/ d41586- 021- 00943-x [Accessed 10 May
2021].
20 Young IM. Justice and the politics of difference. New Jersey:
Princeton University Press, 1990.
21 Young IM. Responsibility for justice. Oxford: Oxford University Press,
2011.
22 Latour B. Down to earth: politics in the new climatic regime.
Cambridge, UK: Polity press, 2018.
on September 30, 2021 by guest. Protected by copyright.http://gh.bmj.com/BMJ Glob Health: first published as 10.1136/bmjgh-2021-007237 on 29 September 2021. Downloaded from
