Volume 7 no 1

The health system is on fire — and it was predictable

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The health system is on fire — and it was predictable

 

https://doi.org/10.37964/cr24727

 

 

COVID-19 has created stresses in all systems, including health care, and the alignment of weaknesses has caused a syndemic. This paper describes how COVID-19 accelerated a collapse that was already in the making. Using a panarchy model, it highlights necessary changes to be made and questions what part of “normal” is worth going back to. Finally, it summarizes experiences and reflections of Canadian health care leaders revealed in interviews held during the first four months of the pandemic.

 

 

KEY WORDS: health care system, pandemic, leadership skills, panarchy cycle

 

CITATION: Van Aerde J. The health system is on fire — and it was predictable. Can J Physician Leadersh 2020;7(1):43-51.

 

Four years ago, I wrote, “The ultimate external crisis [in the health system] can be triggered at any time by an economic collapse or a global pandemic disease.”1 COVID-19 has exposed the internal and external stresses in our human-made systems, including health, economics, and education. The simultaneous alignment of weaknesses in multiple systems has caused a syndemic. This paper describes how the present crisis was predictable and how COVID-19 accelerated a collapse that was already in the making. Using a panarchy model, it highlights necessary changes to be made and questions what part of the previous “normal” is worth going back to. Finally, it summarizes experiences and reflections derived from a series of interviews with Canadian health care leaders held during the first four months of COVID-19. Top

 

Change as renewal: the panarchy model

 

When a complex, adaptive system adjusts to internal and external dynamics, it follows a renewal cycle inside the three-dimensional space of the panarchy model defined by capital, connectedness, and resilience (Figure 1). Capital is the amount of material accumulated, such as biomass, physical structure, and nutrients in a forest, or physical, human, and technological resources in human-made systems. Connectedness refers to the number of links or separation  between agents. Resilience, the opposite of vulnerability, is the capacity of a system to adapt to change and withstand shock without catastrophic failure.2-4

 

Change can be caused by the internal dynamics and stresses of an evolving system as well as the external influences putting pressure on that system. However, before we can explore the panarchy model, we need to define the boundaries of Canadian health and health care as systems.5

 

The Canadian health system: an amalgamation of poorly connected subsystems

The boundaries of the Canadian health care systems are ill-defined except for what was laid out in the Medical Health Act in 1967 and further delineated in the Canada Health Act in 1984,6,7 i.e., the services provided in hospitals and by physicians in hospitals and private offices (Figure 2, circle 1). The deliverables in circle 1 consume the bulk of health care budgets and only contribute in a minor way to health.8,9 The boundaries of the community and the preventive components of the health system are much less well defined (circle 2), and the factors contributing most to health are not part of our health care system at all (circle 3). Top

 

Thus, our health care system deals mostly with disease (circle 1 and some elements of circle 2), while everything that determines health falls mostly outside the system. These multilayered subsystems, all affecting health in different ways, influence each other and are exposed to different pressures.

 

Stages in the panarchy cycle There are four stages in the panarchy cycle: exploitation (birth) and conservation (maturity) in the slow portion and release or collapse (creative destruction) and reorganization (renewal) in the fast part of the cycle.2,10 Using a forest as an example of a complex, adaptive ecosystem, like health care, the conservation stage accumulates and slowly stores energy and material (capital) resulting in a tree population with little diversity and, thus, decreased resilience, that reaches carrying capacity and stabilizes for a while (upper right part of Figure 1). Release occurs rapidly when that tree population collapses because it lacks resistance to an invasive species or disease or because of a forest fire (right side of Figure1). After that crisis, reorganization can also occur rapidly, particularly when certain members of the tree population are selected for their genetic (innovative) ability to survive despite the external or internal pressures on the system (red part of Figure 1).

 

There is no beginning or end to this infinite cycle; destruction of the previous cycle forms the beginning of a new one, but at a transformed level, where many things are different and irreversible. Within the three-dimensional frame, growth toward conservation makes up the slow front portion of the cycle and represents the dominant paradigm, i.e., the way we have seen health care in Canada for the last 50 years. The fast back portion of the cycle represents creative change and renewal.

 

The panarchy model describes Canada’s health system: it’s complex and adaptive How we got to the upper right side of the panarchy model has been described before.1 Briefly, after the second world war, the Canadian health care system was designed and structured to deliver acute care to a young population, for whom the almost exclusive emphasis on hospitals and physician care was sufficient. That era was followed by great medical advances, boundless promises, and ever-growing public expectations, leading to ever-expanding service options and institutions, all characterized by similar types of resources centred around technology and comprehensive hospital care. From a systemic point of view, there was no real innovation in terms of how to keep the population healthy during this growth phase. Top

 

The health care system (circle 1 of Figure 2) developed more and more connections between an increasing number of agents, leading to less and less resilience. Cumulative growth moved the system into the mature conservation phase (Figure 1) of increasing specialization and resource accumulation3 without systemic innovation, leading to an increase in capital and more and more rigidity. The public fear of changing what is considered the only way to deliver health care and the outdated Canada Health Act itself added to the rigidity.11,12 The vested interests of professional organizations, politicians, and pharmaceutical companies have further added to the loss of resilience.13 With an increase in specialization and technology, the need to restructure and integrate the acute care system also increased, which added layers of bureaucracy, amplified the level of government involvement, and increased the degree of connectedness and rigidity even more (Table 1).

 

External pressures were building too (Table 1). The health care system fulfilled fewer of the needs of the changing population: an increasing number of aging baby boomers, more patients with chronic diseases, and consumers demanding more health care services. Unfortunately, there is a conflict between a publicly funded health care system and the expectation that all care must be provided to every Canadian free of charge at all times.6 External pressures on the acute care system arose from the increasing cost of human resources and medications, increasingly complex and expensive technology and procedures, and rising public expectations influenced by biased, sensational news reporting in social and other media. Financial pressures include reduced government revenues resulting from low natural resource prices and recession in the global economy, as well as a shrinking taxpayer base as the population ages. Finally, in 2020, the COVID-19 crisis became the latest external stressor triggering a syndemic that affected not only the health care system, but also many elements of the economic, social, judicial, and educational systems.

 

Stuck in the rigidity trap

 

Eventually, any adaptive complex system breaks down under combined high internal stresses and external pressures, accelerated by one or another trigger, such as the COVID-19 pandemic. Like a forest fire, destruction happens quickly and is a vital step in creating a path for adaptation and innovation.2,3,10 However, although the renewal cycle is normal in ecosystems, it is rarely acceptable in our human-made, economic, educational, health care, and political systems. Thus, people try to extend the growth portion of the cycle indefinitely and avoid the inevitable breakdown, ending up in a rigidity trap, as we did just before the pandemic. Extending the conservation phase into the rigidity trap increases the probability of an even more serious crisis as experienced today.2,4 Top

 

Although we might have expected that the crisis would occur in acute care only, the pandemic has exposed pressures in all three circles (Figure 2). Stresses also accumulated when the health care system (circle 1) learned to displace many of its problems into the hierarchically adjacent circles (2 and 3) with their less clear boundaries.1 The health care system became increasingly competent at managing everything within its boundaries by pushing away components it could not manage well.1 The structured acute care system was taking up larger and larger fractions of available resources, leaving less for creativity and innovation in health-related elements outside circle 1, including primary care, home care, long-term care, prevention, and health promotion.

 

Creative destruction: what’s left after the forest fire?

 

Forms and structures are necessary to deliver services, but they are not the essence of the work. The substance of health care is not the structures of hospitals and clinics or even the professions of physicians and nurses. Rather these are forms that have enabled health care work. As enablers, they are crucial, but they are not the substance of the work.10 What does this mean for organizations or human systems, such as health care? Forms and structures that no longer support the work or mission of a system need to be abolished in a manner that does not destroy the substance of the system, which is compassionate care and serving patients and families. In Canada, this might mean the deconstruction of rigid forms and structures surrounding acute care institutions and redesign of what is needed to serve needs in circles 2 and 3, while preserving our values of fairness, equity, and compassion. Top

 

Personal mental models, cultural beliefs, and biases made people cling to the old forms and structures because they were the keys to success as the health care system was moving toward the maturity phase.10 As a result, creative destruction appears as a threat to clinical professions, politicians, institutions, and the public. However, if led intelligently, it can become the renewal phase for a system geared toward person-centred care and community-based health. Health care leaders, particularly physicians, need to learn this concept to ensure that the substance of health care is not lost, but renewed.

 

Many systemic weaknesses were hidden in the rigidity trap

 

Although cracks already existed before the pandemic, there are now clear fault lines in many systems affecting health: fragility of supply chains; socioeconomic inequities, including homeless-ness, racial inequities, gender inequities; ageism with neglect of the elderly; societal mental health issues, including substance use disorder; burnout in the health care workforce; overdue redefinition of the physician’s role; lack of real patient-centred care; and lack of clarity regarding the Canadian health (care) system’s purpose. Top

 

Limited pandemic preparedness Despite signs of a pending crisis, we did not implement the recommendations emanating from the SARS outbreak or follow up on recent pandemic simulations.14-16 That became obvious very early in the COVID-19 pandemic when shortages of medical supplies and equipment became acute as a result of weak to non-existent supply chains. “Supply chain” was not even part of the vocabulary of world leaders until COVID-19. Now the value and importance of supply chain security for health systems have a much higher profile than ever before. In the future, no country or region should be dependent on a single national or international supply source. For Canada, the Supply Chain Advancement Network (SCAN) in Health is one of the leaders in this development.17 There is also evidence that coordination of supplies and equipment has been easier in provinces with integrated health care systems.

 

Inequities exposed The pandemic didn’t create inequity, it just made the gaps bigger. Although the initial slogan was “We are in this together,” it soon became obvious that although we were all in the same storm, we were in different boats. People living in the poorest neighborhoods, often in overcrowded housing, showed the worst rates of COVID-19 infections.18,19 Marginalized youth and families will need ongoing support so that, now and in the foreseeable future, COVID-19 does not create what the United Nations has termed “a lost generation of young people.”20 The homeless are at even higher risk of infection with severe COVID-19 disease, re-emphasizing the importance of housing as a social determinant of health.21 It is uncertain whether the explosion of protests against racial discrimination would have happened at this time anyway or whether it was triggered by the pent-up emotions of isolation, uncertainty, fear of the pandemic, but the fact is that major societal inequities affecting health will need to addressed as part of the renewal part of the panarchy cycle. Top

 

Gender inequity, overall and in medicine, has come to the forefront again, with women bearing the brunt of household duties and childcare as people retreated into their homes.22 Although many blamed the closure of schools and childcare centres for creating gender inequities, other cultural biases might lie even deeper. Over the ages, our mental models and culture have evolved into a family structure with responsibilities based on maternal caring and nurturing. Do we need to change those mental models? However, that same maternal trait of caring, together with other traditional feminine leadership attributes, such as compassion, humility, and vulnerability, also contributed to the success of women-led countries like New Zealand, Taiwan, and Germany in dealing with COVID-19.23

 

Ageism and long-term care The mortality of the elderly in long-term care facilities is high.24 Lessons on complexity in health care systems have repeatedly used the example of overcrowding of ER and acute beds because of a lack of beds in long-term care facilities and nursing homes. This is an example of an unclear boundary between circles 1 and 2 in Figure 1. The ongoing shortage of beds, understaffing with overworked care providers, and insufficient funds were the underlying causes for the collapse of the long-term care system, triggered by the pandemic. Will the pandemic force Canada to integrate more elements of circles 2 and 3 into the universal health care system, or will it continue to hide behind health acts that don’t include long-term and elderly care?

 

Mental health Societal mental health issues, including substance use disorder, were already rampant before the crisis, and there are signs that they are increasing. Among health care professionals, 25–50% of nurses and physicians showed signs of burnout before the pandemic. What will be the effect on those with increased workloads25 and others who have lost work and income because of the pandemic?

 

Changing roles, purpose, and care delivery It is questionable whether we were practising real patient-centred care before the pandemic. Over the last years, care has been system-centred. The current crisis creates an opportunity to make the system work for patients. In our interviews, it was noted that the patient relationship with the health system has changed over the last six months, and it is likely that patients will no longer come to the “centre of excellence” at the top of the hill. Top

 

The use of virtual care, which has been very slow to be adopted, suddenly accelerated to the satisfaction of patients.26 Virtual care might relieve after-hours pressure on ERs. It also adds convenience for patients, who do not need to travel or wait in an uncomfortable office or ER environment. The sense of urgency and perceived shortage of time frequently experienced during an office visit can be replaced by informative conversations after electronic preparation beforehand. For the health professional, online interaction allows insight into where and how the patient lives. At the same time, the patient “owns” part of the electronic meeting space, unlike during face-to-face office visits. Patients indicate that they don’t miss the “healing touch” most of the time. Finally, virtual care will be particularly helpful for community-centred care and wellness, for some follow-up visits of patients with chronic ailments, and for non-acute or non-surgical visits not requiring physical examination.27

 

The major shifts imposed by the crisis, the changing patient–physician relationship, the presence of virtual care, and the shifting balance between acute and community care indicate that redefining the physician’s role is long overdue. The time has come to define the purpose of the Canadian health (care) system, which was never clear and certainly has not kept up with changes in the last half-century. Will we instead fall back into the panic–neglect cycle, in which crises trigger waves of attention and funding that quickly dissipate once the crisis recedes?

 

Experiences during the pandemic: interviews with Canadian health leaders

 

During the first four months of the pandemic, we interviewed 18 health system leaders: leaders in patient advocacy, virtual care, supply chain management, medical students, and physicians who are a CEO, a minister of health, an astronaut, an innovator, and more. These talks highlighted opportunities and concerns caused by the crisis. (The full interviews are available as podcasts: https://physicianleaders.ca/podcasts.html.)

 

Although the creative destruction phase of the panarchy cycle creates opportunities for the system, for people it brings uncertainty. Good leadership thrives in uncertainty by recognizing that the challenge is to support people and to be agile in exploring possibilities in the renewal phase. Our interviews highlighted leadership qualities important in the current crisis, as well as opportunities, ongoing changes, and concerns, some resonating with the phase of renewal and innovation of the panarchy model.

 

Leadership traits that are vital during crisis The leadership attributes and values deemed most useful during the pandemic (i.e., mentioned in at least three interviews) are listed by LEADS domain28 in Table 2.

 

Communication skills were mentioned in every interview. Listening, both interpersonally and strategically, was seen as vital, not only for building empathy and compassion, but also for gathering information from others. Many interpersonal traits mentioned fall under the LEADS domains of Leads self and Engage others; fewer strategic abilities fall under the Develop coalitions and Systems transformation domains. Although all interviewees implied that prevention of disease and low mortality are results to be achieved, no specific leadership traits for Achieve results were mentioned more than once.

 

Emotional factors influence decisions During a crisis, particularly a long one, leadership can be a lonely journey. That feeling can be attenuated by reaching out, by being kind to self and others, and by creating trust and psychological safety among peers and team members. Loneliness is further aggravated by feelings of guilt — guilt toward self for not doing enough, toward peers over shortage of necessary resources, toward family for fear of bringing home the disease, and toward patients for not being able to offer what should be offered. Top

 

Some leaders mentioned that the guilt feeling can be influenced by our response to the situation. Each of us has a choice between feeling victimized by external conditions or learning what we can control and not control.29 In rapidly changing situations, leaders require courage to implement the best possible decision in the face of uncertainty that comes with incomplete or even erroneous data and limited resources. Accepting that we do the best we can with what we have in different situations requires us to be kind to ourselves.

 

Distributed leadership builds collaboration Many interviewees talked about the need to practise distributed leadership and collaboration, not only to further reduce the feelings of loneliness and guilt, but also to build trust and help with information gathering. Despite practising distributed leadership, the leader might sometimes appear to use a command-and-control style in making decisions; however, by the time a particular decision is made, the leader often has filtered extensive advice and evidence obtained from the diversity of the team or organization. In certain crisis situations, the apparent decisiveness or perception of command and control is needed to sway the day.

 

Psychological safety and trust inspire innovation Almost all interviewees stressed that evidence is often incomplete or partly incorrect. As a result, mistakes are made and decisions need to be revised. This is all part of the normal learning and improvement cycle. It was also said that failure and mistakes are not accepted in the health care system and not tolerated by the medical profession. This risk-adverse culture might work against offering creative ideas during crises, thereby attenuating the chance to discover innovative solutions. In the current crisis, to change that culture and allow people to be creative by learning from mistakes, leaders must create psychological safety within their teams, the organization, and throughout the system. Top

 

It was also noted that building trust is difficult during the collapse phase of the panarchy cycle, and that organizations should create psychological safety and trust beforehand to better weather crises. Some organizations had also prepared their physician leaders in advance by adopting structured leadership development. By investing in advance and by cultivating a trusting leadership presence before the crisis, some organizations created the necessary psychological safety to make leading easier in times of uncertainty. In that kind of environment, leaders themselves also felt supported by the organization to make decisions and take action in the face of uncertainty.

 

Values lead change In times of uncertainty and chaos, core values are our main compass keeping us true to ourselves and who we are. Many mentioned that leaders need the agility and flexibility to apply different leadership and decision-making styles depending on the situation in a rapidly changing environment. That includes being skilled at zooming out systemically, and zooming in to take specific action.30

 

Although core values are the compass for individual leaders, the quadruple aim31 provides four pillars against which health care systems are evaluated. Some interviewees clarified how the quadruple aim is faring during COVID-19.  Better care was initially reduced to minimizing mortality from COVID-19. Accelerating the acceptance of virtual care has improved care, but closure of large sections of hospitals has jeopardized care for “regular” diseases. Will the ongoing changes in care delivery give us better care?

 

The cracks in the health system exposed by the pandemic show that, in the future, better outcomes will necessitate action in many areas outside the traditional health care system. Currently, it means improving outcomes in long-term care facilities. In future analyses, we might see that the outcomes of “regular” pathology deteriorated during the pandemic, including mental illness. In general, we are doing poorly in achieving this aim, now and in the future. Top

 

Lower cost is not a priority right now, but deserves our attention. How the huge financial losses will affect overall investment and distribution across health, health care, and other elements of our society remains to be seen.

 

Well-being of health care workers is a systems value that was already being ignored before the pandemic. For now, leaders can reduce the fear of uncertainty, create psychological safety, and build trust until more permanent structural and cultural systemic changes can be introduced.32

 

The Dalai Lama’s33 first two principles of ethical strategies can guide us in redesigning the health system after the pandemic: “Let’s ensure that compassion is the motivation” and “Any problem must take into account the big picture and long-term consequences rather than short-term feasibility.” Top

 

References

1.Van Aerde J. Panarchy, the collapse of the Canadian health care system, and physician leadership. Can J Physician Leadersh 2016;2(4):103-9.

2.Gunderson LH, Holling CS. Panarchy: understanding transformation in human and natural systems. Washington DC: Island Press; 2002.

3.Stange K, Ferrer R, Miller W. Making sense of health care transformation as adaptive-renewal cycles. Ann Fam Med 2009;7(6):484-8.

4.Homer-Dixon T. Complexity science. Oxford Leadership J 2011;2(1):1-15.

5.Begun JW, Zimmerman B, Dooley KJ. Health care organizations as complex adaptive systems. In Mick S, Wyttenbach ME (editors). Advances in health care organization theory. San Francisco: Jossey-Bass; 2003. pp. 253-88.

6.Picard A. The path to health care reform: policy and politics. Ottawa: Conference Board of Canada; 2012. Available: https://bit.ly/2BTlVpA  (accessed 3 Aug. 2020).

7.Simpson J. Chronic condition: why Canada’s health-care system needs to be dragged into the 21st century. Toronto: Allen Lane; 2012.

8.Neudorf C, Fuller D, Lockhart S, Neudorf J, Plante C, Williams-Roberts H, et al. Changes in social inequalities in health over time in Saskatchewan. Regina: Saskatchewan Health Research Foundation; 2016. http://tinyurl.com/zafx65d  (accessed 11 Aug. 2020).

9.Marmot M. The health gap. New York: Bloomsbury Press; 2015.

10.Zimmerman B. From lifecycle to ecocycle: renewal through destruction and encouraging diversity for sustainability. In Zimmerman B, Lindberg C, Plsek P (editors). Edgeware: lessons from complexity science for health care leaders. Bordentown, NJ: Plexus Institute; 2008. pp. 171-84.

11.Clemens J, Semail N. First do no harm: how the Canada Health Act obstructs reform and innovation. Ottawa: MacDonald-Laurier Institute; 2012. http://tinyurl.com/jl6oj9y  (accessed 3 Aug. 2020).

12.Marchildon GP, Di Matteo L (editors). Bending the cost curve in health care. Toronto: University of Toronto Press; 2015.

13.Lazar H, Lavis J, Forest PG, Church J. Paradigm freeze: why it is so hard to reform health-care policy in Canada. Kingston: McGill-Queen’s University Press; 2013.

14.National Advisory Committee on SARS and Public Health. Learning from SARS: renewal of public health in Canada. Ottawa Public Health Agency of Canada; 2003. Available: https://tinyurl.com/yd99473j (accessed 2 Aug. 2020).

15.Public-private cooperation for pandemic preparedness and response: a call to action. Johns Hopkins Center for Health Security, World Economic Forum, Bill & Melinda Gates Foundation; 2019. Available: https://tinyurl.com/yxf6yj43 (accessed 2 Aug. 2020).

16.Gibson V. How Ontario planned for a crisis before COVID-19 hit. Ottawa: iPolitics; 2020. https://tinyurl.com/yxontklr (accessed 2 Aug. 2020).

17.CIHR COVID-19 rapid research response. Windsor, Ont.: Supply Chain Advancement Network in Health; 2020. https://scanhealth.ca/covid-19-research (accessed 3 Sept. 2020).

18.Grant K. Data show poverty, overcrowded housing connected to COVID-19 rates among racial minorities in Toronto. Globe and Mail 2020;2 July. Available: https://tinyurl.com/yyaw4az5 (accessed 2 Aug. 2020).

19.Emeruwa UN, Ona S, Shaman JL, Turitz A, Wright JD, et al. Associations between built environment, neighborhood socioeconomic status, and SARS-CoV-2 infection among pregnant women in New York City. JAMA 2020;324(4):390-2. https://doi.org/10.1001/jama.2020.11370

20.World cannot afford lost generation, Secretary-General stresses, in remarks marking fifth anniversary of Youth, Peace and Security Agenda. New York: United Nations; 2020. Available: https://bit.ly/2Dq0VaI (accessed 3 Sept. 2020).

21.Perri M, Dosani N, Hwang SW. COVID-19 and people experiencing homelessness: challenges and mitigation strategies. CMAJ 2020;192(26):E716-9. https://doi.org/10.1503/cmaj.200834

22.Brubaker L. Women physicians and the COVID-19 pandemic. JAMA 2020;324(9):835-6. https://doi.org/10.1001/jama.2020.14797

23.Chamorro-Premuzic Tm Wittenberg-Cox A. Will the pandemic reshape notions of female leadership? Harv Bus Rev 2020;26 June. https://tinyurl.com/yxvoxtdf (accessed 14 July 2020).

24.Pandemic experience in the long-term care sector: how does Canada compare with other countries. Ottawa: Canadian Institute for Health Information; 2020. https://bit.ly/3frwqxY (accessed 3 Aug. 2020).

25.Bielski Z. In sickness and in health: COVID-19 pandemic stress tests marriages of health care workers on the front lines. Globe and Mail 2020;2 Aug. https://tgam.ca/2D6KmRb (accessed 3 Aug. 2020).

26.What Canadians think about virtual health care. Ottawa; Canadian Medical Association; 2020. https://bit.ly/3kK8hXm (accessed 3 Aug. 2020).

27.Renault M. What a doctor learns from watching you on video chat. Atlantic 2020;6 Aug. https://bit.ly/3acwpx2 (accessed 7 Aug. 2020).

28.Dickson G, Tholl. 2020. Bringing LEADS to life in health: LEADS in a caring environment (2nd ed.). Cham, Switzerland: Springer; 2020.

29.Van Aerde J. Control and influence, let go of the rest. Can J Physician Leadersh 2020;6(4):146-8.

30.Van Aerde J. Agile, servant, and compassionate leadership: antidotes to perfectionism during uncertainty. Can J Physician Leadersh 2020;6(4):165-7.

31.Bodemheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med 2014;2(6):573-6. https://doi.org/10.1370/afm.1713

32.Psychological PPE: promote health care workforce mental health and well-being. Boston: Institute for Healthcare Improvement; 2020. https://bit.ly/30HzyBM (accessed 10 Aug. 2020).

33.Dalai Lama. Principles for ethical strategies. In The universe in a single atom. New York: Harmony Books; 2005, p. 200.

 

Acknowledgements

The Canadian Society of Physician Leaders and CJPL thank everyone who kindly consented to be interviewed. Full interviews can be found at physicianleaders.ca/podcasts.html

 

Author

Johny Van Aerde, MD, PhD, FRCPC, is editor-in-chief of the Canadian Journal of Physician Leadership and executive medical director of the Canadian Society of Physician Leaders.

 

Correspondence to:

johny.vanaerde@gmail.com

 

This article has been peer reviewed.

 

Top

The health system is on fire — and it was predictable

 

https://doi.org/10.37964/cr24727

 

 

COVID-19 has created stresses in all systems, including health care, and the alignment of weaknesses has caused a syndemic. This paper describes how COVID-19 accelerated a collapse that was already in the making. Using a panarchy model, it highlights necessary changes to be made and questions what part of “normal” is worth going back to. Finally, it summarizes experiences and reflections of Canadian health care leaders revealed in interviews held during the first four months of the pandemic.

 

 

KEY WORDS: health care system, pandemic, leadership skills, panarchy cycle

 

CITATION: Van Aerde J. The health system is on fire — and it was predictable. Can J Physician Leadersh 2020;7(1):43-51.

 

Four years ago, I wrote, “The ultimate external crisis [in the health system] can be triggered at any time by an economic collapse or a global pandemic disease.”1 COVID-19 has exposed the internal and external stresses in our human-made systems, including health, economics, and education. The simultaneous alignment of weaknesses in multiple systems has caused a syndemic. This paper describes how the present crisis was predictable and how COVID-19 accelerated a collapse that was already in the making. Using a panarchy model, it highlights necessary changes to be made and questions what part of the previous “normal” is worth going back to. Finally, it summarizes experiences and reflections derived from a series of interviews with Canadian health care leaders held during the first four months of COVID-19. Top

 

Change as renewal: the panarchy model

 

When a complex, adaptive system adjusts to internal and external dynamics, it follows a renewal cycle inside the three-dimensional space of the panarchy model defined by capital, connectedness, and resilience (Figure 1). Capital is the amount of material accumulated, such as biomass, physical structure, and nutrients in a forest, or physical, human, and technological resources in human-made systems. Connectedness refers to the number of links or separation  between agents. Resilience, the opposite of vulnerability, is the capacity of a system to adapt to change and withstand shock without catastrophic failure.2-4

 

Change can be caused by the internal dynamics and stresses of an evolving system as well as the external influences putting pressure on that system. However, before we can explore the panarchy model, we need to define the boundaries of Canadian health and health care as systems.5

 

The Canadian health system: an amalgamation of poorly connected subsystems

The boundaries of the Canadian health care systems are ill-defined except for what was laid out in the Medical Health Act in 1967 and further delineated in the Canada Health Act in 1984,6,7 i.e., the services provided in hospitals and by physicians in hospitals and private offices (Figure 2, circle 1). The deliverables in circle 1 consume the bulk of health care budgets and only contribute in a minor way to health.8,9 The boundaries of the community and the preventive components of the health system are much less well defined (circle 2), and the factors contributing most to health are not part of our health care system at all (circle 3). Top

 

Thus, our health care system deals mostly with disease (circle 1 and some elements of circle 2), while everything that determines health falls mostly outside the system. These multilayered subsystems, all affecting health in different ways, influence each other and are exposed to different pressures.

 

Stages in the panarchy cycle There are four stages in the panarchy cycle: exploitation (birth) and conservation (maturity) in the slow portion and release or collapse (creative destruction) and reorganization (renewal) in the fast part of the cycle.2,10 Using a forest as an example of a complex, adaptive ecosystem, like health care, the conservation stage accumulates and slowly stores energy and material (capital) resulting in a tree population with little diversity and, thus, decreased resilience, that reaches carrying capacity and stabilizes for a while (upper right part of Figure 1). Release occurs rapidly when that tree population collapses because it lacks resistance to an invasive species or disease or because of a forest fire (right side of Figure1). After that crisis, reorganization can also occur rapidly, particularly when certain members of the tree population are selected for their genetic (innovative) ability to survive despite the external or internal pressures on the system (red part of Figure 1).

 

There is no beginning or end to this infinite cycle; destruction of the previous cycle forms the beginning of a new one, but at a transformed level, where many things are different and irreversible. Within the three-dimensional frame, growth toward conservation makes up the slow front portion of the cycle and represents the dominant paradigm, i.e., the way we have seen health care in Canada for the last 50 years. The fast back portion of the cycle represents creative change and renewal.

 

The panarchy model describes Canada’s health system: it’s complex and adaptive How we got to the upper right side of the panarchy model has been described before.1 Briefly, after the second world war, the Canadian health care system was designed and structured to deliver acute care to a young population, for whom the almost exclusive emphasis on hospitals and physician care was sufficient. That era was followed by great medical advances, boundless promises, and ever-growing public expectations, leading to ever-expanding service options and institutions, all characterized by similar types of resources centred around technology and comprehensive hospital care. From a systemic point of view, there was no real innovation in terms of how to keep the population healthy during this growth phase. Top

 

The health care system (circle 1 of Figure 2) developed more and more connections between an increasing number of agents, leading to less and less resilience. Cumulative growth moved the system into the mature conservation phase (Figure 1) of increasing specialization and resource accumulation3 without systemic innovation, leading to an increase in capital and more and more rigidity. The public fear of changing what is considered the only way to deliver health care and the outdated Canada Health Act itself added to the rigidity.11,12 The vested interests of professional organizations, politicians, and pharmaceutical companies have further added to the loss of resilience.13 With an increase in specialization and technology, the need to restructure and integrate the acute care system also increased, which added layers of bureaucracy, amplified the level of government involvement, and increased the degree of connectedness and rigidity even more (Table 1).

 

External pressures were building too (Table 1). The health care system fulfilled fewer of the needs of the changing population: an increasing number of aging baby boomers, more patients with chronic diseases, and consumers demanding more health care services. Unfortunately, there is a conflict between a publicly funded health care system and the expectation that all care must be provided to every Canadian free of charge at all times.6 External pressures on the acute care system arose from the increasing cost of human resources and medications, increasingly complex and expensive technology and procedures, and rising public expectations influenced by biased, sensational news reporting in social and other media. Financial pressures include reduced government revenues resulting from low natural resource prices and recession in the global economy, as well as a shrinking taxpayer base as the population ages. Finally, in 2020, the COVID-19 crisis became the latest external stressor triggering a syndemic that affected not only the health care system, but also many elements of the economic, social, judicial, and educational systems.

 

Stuck in the rigidity trap

 

Eventually, any adaptive complex system breaks down under combined high internal stresses and external pressures, accelerated by one or another trigger, such as the COVID-19 pandemic. Like a forest fire, destruction happens quickly and is a vital step in creating a path for adaptation and innovation.2,3,10 However, although the renewal cycle is normal in ecosystems, it is rarely acceptable in our human-made, economic, educational, health care, and political systems. Thus, people try to extend the growth portion of the cycle indefinitely and avoid the inevitable breakdown, ending up in a rigidity trap, as we did just before the pandemic. Extending the conservation phase into the rigidity trap increases the probability of an even more serious crisis as experienced today.2,4 Top

 

Although we might have expected that the crisis would occur in acute care only, the pandemic has exposed pressures in all three circles (Figure 2). Stresses also accumulated when the health care system (circle 1) learned to displace many of its problems into the hierarchically adjacent circles (2 and 3) with their less clear boundaries.1 The health care system became increasingly competent at managing everything within its boundaries by pushing away components it could not manage well.1 The structured acute care system was taking up larger and larger fractions of available resources, leaving less for creativity and innovation in health-related elements outside circle 1, including primary care, home care, long-term care, prevention, and health promotion.

 

Creative destruction: what’s left after the forest fire?

 

Forms and structures are necessary to deliver services, but they are not the essence of the work. The substance of health care is not the structures of hospitals and clinics or even the professions of physicians and nurses. Rather these are forms that have enabled health care work. As enablers, they are crucial, but they are not the substance of the work.10 What does this mean for organizations or human systems, such as health care? Forms and structures that no longer support the work or mission of a system need to be abolished in a manner that does not destroy the substance of the system, which is compassionate care and serving patients and families. In Canada, this might mean the deconstruction of rigid forms and structures surrounding acute care institutions and redesign of what is needed to serve needs in circles 2 and 3, while preserving our values of fairness, equity, and compassion. Top

 

Personal mental models, cultural beliefs, and biases made people cling to the old forms and structures because they were the keys to success as the health care system was moving toward the maturity phase.10 As a result, creative destruction appears as a threat to clinical professions, politicians, institutions, and the public. However, if led intelligently, it can become the renewal phase for a system geared toward person-centred care and community-based health. Health care leaders, particularly physicians, need to learn this concept to ensure that the substance of health care is not lost, but renewed.

 

Many systemic weaknesses were hidden in the rigidity trap

 

Although cracks already existed before the pandemic, there are now clear fault lines in many systems affecting health: fragility of supply chains; socioeconomic inequities, including homeless-ness, racial inequities, gender inequities; ageism with neglect of the elderly; societal mental health issues, including substance use disorder; burnout in the health care workforce; overdue redefinition of the physician’s role; lack of real patient-centred care; and lack of clarity regarding the Canadian health (care) system’s purpose. Top

 

Limited pandemic preparedness Despite signs of a pending crisis, we did not implement the recommendations emanating from the SARS outbreak or follow up on recent pandemic simulations.14-16 That became obvious very early in the COVID-19 pandemic when shortages of medical supplies and equipment became acute as a result of weak to non-existent supply chains. “Supply chain” was not even part of the vocabulary of world leaders until COVID-19. Now the value and importance of supply chain security for health systems have a much higher profile than ever before. In the future, no country or region should be dependent on a single national or international supply source. For Canada, the Supply Chain Advancement Network (SCAN) in Health is one of the leaders in this development.17 There is also evidence that coordination of supplies and equipment has been easier in provinces with integrated health care systems.

 

Inequities exposed The pandemic didn’t create inequity, it just made the gaps bigger. Although the initial slogan was “We are in this together,” it soon became obvious that although we were all in the same storm, we were in different boats. People living in the poorest neighborhoods, often in overcrowded housing, showed the worst rates of COVID-19 infections.18,19 Marginalized youth and families will need ongoing support so that, now and in the foreseeable future, COVID-19 does not create what the United Nations has termed “a lost generation of young people.”20 The homeless are at even higher risk of infection with severe COVID-19 disease, re-emphasizing the importance of housing as a social determinant of health.21 It is uncertain whether the explosion of protests against racial discrimination would have happened at this time anyway or whether it was triggered by the pent-up emotions of isolation, uncertainty, fear of the pandemic, but the fact is that major societal inequities affecting health will need to addressed as part of the renewal part of the panarchy cycle. Top

 

Gender inequity, overall and in medicine, has come to the forefront again, with women bearing the brunt of household duties and childcare as people retreated into their homes.22 Although many blamed the closure of schools and childcare centres for creating gender inequities, other cultural biases might lie even deeper. Over the ages, our mental models and culture have evolved into a family structure with responsibilities based on maternal caring and nurturing. Do we need to change those mental models? However, that same maternal trait of caring, together with other traditional feminine leadership attributes, such as compassion, humility, and vulnerability, also contributed to the success of women-led countries like New Zealand, Taiwan, and Germany in dealing with COVID-19.23

 

Ageism and long-term care The mortality of the elderly in long-term care facilities is high.24 Lessons on complexity in health care systems have repeatedly used the example of overcrowding of ER and acute beds because of a lack of beds in long-term care facilities and nursing homes. This is an example of an unclear boundary between circles 1 and 2 in Figure 1. The ongoing shortage of beds, understaffing with overworked care providers, and insufficient funds were the underlying causes for the collapse of the long-term care system, triggered by the pandemic. Will the pandemic force Canada to integrate more elements of circles 2 and 3 into the universal health care system, or will it continue to hide behind health acts that don’t include long-term and elderly care?

 

Mental health Societal mental health issues, including substance use disorder, were already rampant before the crisis, and there are signs that they are increasing. Among health care professionals, 25–50% of nurses and physicians showed signs of burnout before the pandemic. What will be the effect on those with increased workloads25 and others who have lost work and income because of the pandemic?

 

Changing roles, purpose, and care delivery It is questionable whether we were practising real patient-centred care before the pandemic. Over the last years, care has been system-centred. The current crisis creates an opportunity to make the system work for patients. In our interviews, it was noted that the patient relationship with the health system has changed over the last six months, and it is likely that patients will no longer come to the “centre of excellence” at the top of the hill. Top

 

The use of virtual care, which has been very slow to be adopted, suddenly accelerated to the satisfaction of patients.26 Virtual care might relieve after-hours pressure on ERs. It also adds convenience for patients, who do not need to travel or wait in an uncomfortable office or ER environment. The sense of urgency and perceived shortage of time frequently experienced during an office visit can be replaced by informative conversations after electronic preparation beforehand. For the health professional, online interaction allows insight into where and how the patient lives. At the same time, the patient “owns” part of the electronic meeting space, unlike during face-to-face office visits. Patients indicate that they don’t miss the “healing touch” most of the time. Finally, virtual care will be particularly helpful for community-centred care and wellness, for some follow-up visits of patients with chronic ailments, and for non-acute or non-surgical visits not requiring physical examination.27

 

The major shifts imposed by the crisis, the changing patient–physician relationship, the presence of virtual care, and the shifting balance between acute and community care indicate that redefining the physician’s role is long overdue. The time has come to define the purpose of the Canadian health (care) system, which was never clear and certainly has not kept up with changes in the last half-century. Will we instead fall back into the panic–neglect cycle, in which crises trigger waves of attention and funding that quickly dissipate once the crisis recedes?

 

Experiences during the pandemic: interviews with Canadian health leaders

 

During the first four months of the pandemic, we interviewed 18 health system leaders: leaders in patient advocacy, virtual care, supply chain management, medical students, and physicians who are a CEO, a minister of health, an astronaut, an innovator, and more. These talks highlighted opportunities and concerns caused by the crisis. (The full interviews are available as podcasts: https://physicianleaders.ca/podcasts.html.)

 

Although the creative destruction phase of the panarchy cycle creates opportunities for the system, for people it brings uncertainty. Good leadership thrives in uncertainty by recognizing that the challenge is to support people and to be agile in exploring possibilities in the renewal phase. Our interviews highlighted leadership qualities important in the current crisis, as well as opportunities, ongoing changes, and concerns, some resonating with the phase of renewal and innovation of the panarchy model.

 

Leadership traits that are vital during crisis The leadership attributes and values deemed most useful during the pandemic (i.e., mentioned in at least three interviews) are listed by LEADS domain28 in Table 2.

 

Communication skills were mentioned in every interview. Listening, both interpersonally and strategically, was seen as vital, not only for building empathy and compassion, but also for gathering information from others. Many interpersonal traits mentioned fall under the LEADS domains of Leads self and Engage others; fewer strategic abilities fall under the Develop coalitions and Systems transformation domains. Although all interviewees implied that prevention of disease and low mortality are results to be achieved, no specific leadership traits for Achieve results were mentioned more than once.

 

Emotional factors influence decisions During a crisis, particularly a long one, leadership can be a lonely journey. That feeling can be attenuated by reaching out, by being kind to self and others, and by creating trust and psychological safety among peers and team members. Loneliness is further aggravated by feelings of guilt — guilt toward self for not doing enough, toward peers over shortage of necessary resources, toward family for fear of bringing home the disease, and toward patients for not being able to offer what should be offered. Top

 

Some leaders mentioned that the guilt feeling can be influenced by our response to the situation. Each of us has a choice between feeling victimized by external conditions or learning what we can control and not control.29 In rapidly changing situations, leaders require courage to implement the best possible decision in the face of uncertainty that comes with incomplete or even erroneous data and limited resources. Accepting that we do the best we can with what we have in different situations requires us to be kind to ourselves.

 

Distributed leadership builds collaboration Many interviewees talked about the need to practise distributed leadership and collaboration, not only to further reduce the feelings of loneliness and guilt, but also to build trust and help with information gathering. Despite practising distributed leadership, the leader might sometimes appear to use a command-and-control style in making decisions; however, by the time a particular decision is made, the leader often has filtered extensive advice and evidence obtained from the diversity of the team or organization. In certain crisis situations, the apparent decisiveness or perception of command and control is needed to sway the day.

 

Psychological safety and trust inspire innovation Almost all interviewees stressed that evidence is often incomplete or partly incorrect. As a result, mistakes are made and decisions need to be revised. This is all part of the normal learning and improvement cycle. It was also said that failure and mistakes are not accepted in the health care system and not tolerated by the medical profession. This risk-adverse culture might work against offering creative ideas during crises, thereby attenuating the chance to discover innovative solutions. In the current crisis, to change that culture and allow people to be creative by learning from mistakes, leaders must create psychological safety within their teams, the organization, and throughout the system. Top

 

It was also noted that building trust is difficult during the collapse phase of the panarchy cycle, and that organizations should create psychological safety and trust beforehand to better weather crises. Some organizations had also prepared their physician leaders in advance by adopting structured leadership development. By investing in advance and by cultivating a trusting leadership presence before the crisis, some organizations created the necessary psychological safety to make leading easier in times of uncertainty. In that kind of environment, leaders themselves also felt supported by the organization to make decisions and take action in the face of uncertainty.

 

Values lead change In times of uncertainty and chaos, core values are our main compass keeping us true to ourselves and who we are. Many mentioned that leaders need the agility and flexibility to apply different leadership and decision-making styles depending on the situation in a rapidly changing environment. That includes being skilled at zooming out systemically, and zooming in to take specific action.30

 

Although core values are the compass for individual leaders, the quadruple aim31 provides four pillars against which health care systems are evaluated. Some interviewees clarified how the quadruple aim is faring during COVID-19.  Better care was initially reduced to minimizing mortality from COVID-19. Accelerating the acceptance of virtual care has improved care, but closure of large sections of hospitals has jeopardized care for “regular” diseases. Will the ongoing changes in care delivery give us better care?

 

The cracks in the health system exposed by the pandemic show that, in the future, better outcomes will necessitate action in many areas outside the traditional health care system. Currently, it means improving outcomes in long-term care facilities. In future analyses, we might see that the outcomes of “regular” pathology deteriorated during the pandemic, including mental illness. In general, we are doing poorly in achieving this aim, now and in the future. Top

 

Lower cost is not a priority right now, but deserves our attention. How the huge financial losses will affect overall investment and distribution across health, health care, and other elements of our society remains to be seen.

 

Well-being of health care workers is a systems value that was already being ignored before the pandemic. For now, leaders can reduce the fear of uncertainty, create psychological safety, and build trust until more permanent structural and cultural systemic changes can be introduced.32

 

The Dalai Lama’s33 first two principles of ethical strategies can guide us in redesigning the health system after the pandemic: “Let’s ensure that compassion is the motivation” and “Any problem must take into account the big picture and long-term consequences rather than short-term feasibility.” Top

 

References

1.Van Aerde J. Panarchy, the collapse of the Canadian health care system, and physician leadership. Can J Physician Leadersh 2016;2(4):103-9.

2.Gunderson LH, Holling CS. Panarchy: understanding transformation in human and natural systems. Washington DC: Island Press; 2002.

3.Stange K, Ferrer R, Miller W. Making sense of health care transformation as adaptive-renewal cycles. Ann Fam Med 2009;7(6):484-8.

4.Homer-Dixon T. Complexity science. Oxford Leadership J 2011;2(1):1-15.

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6.Picard A. The path to health care reform: policy and politics. Ottawa: Conference Board of Canada; 2012. Available: https://bit.ly/2BTlVpA  (accessed 3 Aug. 2020).

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9.Marmot M. The health gap. New York: Bloomsbury Press; 2015.

10.Zimmerman B. From lifecycle to ecocycle: renewal through destruction and encouraging diversity for sustainability. In Zimmerman B, Lindberg C, Plsek P (editors). Edgeware: lessons from complexity science for health care leaders. Bordentown, NJ: Plexus Institute; 2008. pp. 171-84.

11.Clemens J, Semail N. First do no harm: how the Canada Health Act obstructs reform and innovation. Ottawa: MacDonald-Laurier Institute; 2012. http://tinyurl.com/jl6oj9y  (accessed 3 Aug. 2020).

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13.Lazar H, Lavis J, Forest PG, Church J. Paradigm freeze: why it is so hard to reform health-care policy in Canada. Kingston: McGill-Queen’s University Press; 2013.

14.National Advisory Committee on SARS and Public Health. Learning from SARS: renewal of public health in Canada. Ottawa Public Health Agency of Canada; 2003. Available: https://tinyurl.com/yd99473j (accessed 2 Aug. 2020).

15.Public-private cooperation for pandemic preparedness and response: a call to action. Johns Hopkins Center for Health Security, World Economic Forum, Bill & Melinda Gates Foundation; 2019. Available: https://tinyurl.com/yxf6yj43 (accessed 2 Aug. 2020).

16.Gibson V. How Ontario planned for a crisis before COVID-19 hit. Ottawa: iPolitics; 2020. https://tinyurl.com/yxontklr (accessed 2 Aug. 2020).

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18.Grant K. Data show poverty, overcrowded housing connected to COVID-19 rates among racial minorities in Toronto. Globe and Mail 2020;2 July. Available: https://tinyurl.com/yyaw4az5 (accessed 2 Aug. 2020).

19.Emeruwa UN, Ona S, Shaman JL, Turitz A, Wright JD, et al. Associations between built environment, neighborhood socioeconomic status, and SARS-CoV-2 infection among pregnant women in New York City. JAMA 2020;324(4):390-2. https://doi.org/10.1001/jama.2020.11370

20.World cannot afford lost generation, Secretary-General stresses, in remarks marking fifth anniversary of Youth, Peace and Security Agenda. New York: United Nations; 2020. Available: https://bit.ly/2Dq0VaI (accessed 3 Sept. 2020).

21.Perri M, Dosani N, Hwang SW. COVID-19 and people experiencing homelessness: challenges and mitigation strategies. CMAJ 2020;192(26):E716-9. https://doi.org/10.1503/cmaj.200834

22.Brubaker L. Women physicians and the COVID-19 pandemic. JAMA 2020;324(9):835-6. https://doi.org/10.1001/jama.2020.14797

23.Chamorro-Premuzic Tm Wittenberg-Cox A. Will the pandemic reshape notions of female leadership? Harv Bus Rev 2020;26 June. https://tinyurl.com/yxvoxtdf (accessed 14 July 2020).

24.Pandemic experience in the long-term care sector: how does Canada compare with other countries. Ottawa: Canadian Institute for Health Information; 2020. https://bit.ly/3frwqxY (accessed 3 Aug. 2020).

25.Bielski Z. In sickness and in health: COVID-19 pandemic stress tests marriages of health care workers on the front lines. Globe and Mail 2020;2 Aug. https://tgam.ca/2D6KmRb (accessed 3 Aug. 2020).

26.What Canadians think about virtual health care. Ottawa; Canadian Medical Association; 2020. https://bit.ly/3kK8hXm (accessed 3 Aug. 2020).

27.Renault M. What a doctor learns from watching you on video chat. Atlantic 2020;6 Aug. https://bit.ly/3acwpx2 (accessed 7 Aug. 2020).

28.Dickson G, Tholl. 2020. Bringing LEADS to life in health: LEADS in a caring environment (2nd ed.). Cham, Switzerland: Springer; 2020.

29.Van Aerde J. Control and influence, let go of the rest. Can J Physician Leadersh 2020;6(4):146-8.

30.Van Aerde J. Agile, servant, and compassionate leadership: antidotes to perfectionism during uncertainty. Can J Physician Leadersh 2020;6(4):165-7.

31.Bodemheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med 2014;2(6):573-6. https://doi.org/10.1370/afm.1713

32.Psychological PPE: promote health care workforce mental health and well-being. Boston: Institute for Healthcare Improvement; 2020. https://bit.ly/30HzyBM (accessed 10 Aug. 2020).

33.Dalai Lama. Principles for ethical strategies. In The universe in a single atom. New York: Harmony Books; 2005, p. 200.

 

Acknowledgements

The Canadian Society of Physician Leaders and CJPL thank everyone who kindly consented to be interviewed. Full interviews can be found at physicianleaders.ca/podcasts.html

 

Author

Johny Van Aerde, MD, PhD, FRCPC, is editor-in-chief of the Canadian Journal of Physician Leadership and executive medical director of the Canadian Society of Physician Leaders.

 

Correspondence to:

johny.vanaerde@gmail.com

 

This article has been peer reviewed.

 

Top

When a complex, adaptive system adjusts to internal and external dynamics, it follows a renewal cycle inside the three-dimensional space of the panarchy model defined by capital, connectedness, and resilience (Figure 1). Capital is the amount of material accumulated, such as biomass, physical structure, and nutrients in a forest, or physical, human, and technological resources in human-made systems. Connectedness refers to the number of links or separation  between agents. Resilience, the opposite of vulnerability, is the capacity of a system to adapt to change and withstand shock without catastrophic failure.2-4