Sabka saath in the times of corona
There is a common problem in the medical response to any mass disaster in India; where an already overburdened system becomes dysfunctional under the strain of large numbers.
Sanjay Nagral
March 20, 2020, Mumbai Mirror
A few weeks ago, in this column I had described a scene from the 1992 riots in Mumbai. As the surgeon on duty then, I had to deal with a large number of people with bullet wounds brought to KEM Hospital, but the system designed to deal with limited numbers had collapsed. As a result, we were unable save people who could have otherwise been treated. This is a common problem in the medical response to any mass disaster in India where an already overburdened system becomes dysfunctional under the strain of large numbers.
A few years back, we embarked on a multi-centre study of emergency visits to the casualty departments of three large public hospitals across India. The data from the hospital in Mumbai where I work shows that almost 90 per cent of patients seeking care in a casualty department have minor injuries, which could easily be treated at a lesser facility. The large crowd and chaos delays appropriate care for those in greater need of emergency care.
This is a very old, global problem. In the history of humankind, not only did wars wreak havoc and destruction but also taught us bigger lessons. Many of these lessons are now used to deal with mass disasters. One of which is a vital idea called ‘triage’. The history of triage is inextricably linked with Napoleon Bonaparte and his wars. Napoleon was losing a lot of his soldiers to delays in attending to battle injuries. His army surgeons Percy and Larrey designed triage to help save lives and the model was adopted by the French military in 1801. The system involved categorisation into three grades based on the severity of the wounds irrespective of the soldier’s rank: dangerously wounded, less dangerously wounded, and slightly wounded.
Triage is now accepted as a standard method of rapidly assessing and categorising victims of any mass disasters. The most serious ones are treated first or referred to a bigger facility, followed by the less serious ones. This allows the medical team to focus on those who need urgent care. Over time quick, easy to perform and reliable parameters have been developed to develop triage scores, especially in the case of disasters that result in large number of injuries. It is now standard practice in the developed world. Triaging can be done with the help of ticking a list even by non-expert volunteers. Nationally organised universal health systems have triage protocols at their core.
Advances in modern medicine are often equated with the development of vaccines, drugs, surgery and technology. While this is largely true, the improved outcomes of disease are also due to the evolution and implementation of ideas like triage, which relate to the way health systems are organised. Concepts like triage, referral, centralisation and safety protocols, including checklists, are not about technology or money but logistic ideas. They have played a critical role in improving the outcomes in modern health care.
Triaging has also been at the heart of the approach to the coronavirus epidemic in many countries. It has been used to identify patients at risk, those needing admissions and those needing ICU care. China used it effectively to screen patients arriving with fever. The Italians are using it for deciding who goes into intensive care. A rather disturbing form of triage implemented in Italy is to prioritise ICU care for those likely to survive. When the very elderly with other illnesses compete with younger healthier patients for an ICU bed, the younger ones are prioritised. It’s a form of rationing of resources. Steps like this need social consensus of the highest order but seem inevitable in the current crisis.
Health care in India has largely been run without triaging and protocols. Ideas like this are supposed to be neutral to class, hierarchy and power, which is a big challenge in India. An inequitable form of social triaging where the privileged get care at their beck and call, while the poor languish is already operational. While the creation of testing facilities, isolation beds and intensive care facilities is urgent, systematic and transparent triaging, timely referral and safe transport will also play a key role in the days to come. But for any collective effort, facilities in both public and private sectors will have to be harmonised and close ranks. The closest health facility will have to be determined by distance and not costs. Charges in the private sector will have to be subsidised or funded by the state. And the privileged will also have to fall in line.
This will not happen with voluntary appeals and emotional calls to solidarity but by determined and decisive state intervention. Faced with a huge threat, the Spanish nationalised their small private health care sector, including pharmaceutical manufacture a few days ago. If all this sounds ‘idealistic’ ‘impractical’ or even ‘impossible’ that’s because having been only exposed to a dichotomous system we seem to be unable to grasp that there is another way. For effective intervention in this epidemic, organised universal care will be as important as medicines and ventilators. If our political class, and even all of us, ever had an opportunity to effectively translate slogans like ‘Sabka Saath’ into action, here is one.