The second COVID-19 wave has hit India with great ferocity. It’s déjà vu and more. Family, friends and colleagues are infected, hospitals are flooded with patients, there is a shortage of beds, and ambulances are screaming through the streets. There are curfews and lockdowns, and death is in the air. But there is something different about this wave. Apart from the difference in the disease pattern (infectivity is higher and younger people are being affected), a larger proportion of the elite has been infected. In Mumbai, high-rises have been more affected than slums. The elite have been rudely exposed to the dysfunctionality of our healthcare system which the poor have endured for years. The secure world of the privileged has been exposed. Imbalance between demand and supply of healthcare facilities is not peculiar to India. But there is something in our social DNA that could be making it worse.
Categorising patients based on severity
A time-tested, effective strategy to face the challenge of a sudden large load on the healthcare system is the concept of ‘triage’. This means that when there are a large number of people needing urgent care and there are limited resources, the victims are divided into multiple categories based on severity of disease. The most severe are treated first as any delay will cost lives. The rest are treated later as per their level of severity. This idea was first introduced by Napoleon’s military surgeons to treat battlefield injuries and showed immediate impact. It is now standard practice in many countries when treating mass casualties. It has also been used effectively during COVID-19 .
But triage is not a sterile, mechanical protocol insulated from its surroundings. Its wide acceptance and implementation are based on the powerful but complex principles of justice and solidarity. It is where the interests of everyone are put above the interest of an individual; where those who need care first are prioritised over those who can wait, irrespective of who they are. It works when there is social consensus on a level playing field.
Right from the first wave, Mumbai has witnessed a rather unique effort by the Municipal Corporation to set up a single-window portal of helplines for hospital beds . For the first time, this includes both the public and private sector. There is, of course, an inherent bias in that the public beds are free but the private ones are paid though the charges are capped. A tiered system of observation, oxygen and ICU facilities is in place on paper. However, a few weeks ago, a rather exasperated Municipal Commissioner of Mumbai said that the system is under strain because people are insisting on private hospital beds.
It would be unfair to fault a new Commissioner for a duality that has been cultivated over the years. I doubt whether many of us would easily use a public hospital today. After all, by design or habit, the sanitised world of private medicine is what the privileged have inhabited for years. Moreover, it is hard to remember any senior bureaucrat, politician or even doctor who has chosen to be treated in a public hospital in Mumbai for COVID-19. Even as the Municipal Commissioner was complaining, asymptomatic or mildly symptomatic people such as Sachin Tendulkar, Akshay Kumar and Rashmi Thackeray were admitted to large private hospitals as “abundant precaution”. There are many individuals admitted to private hospitals because they fear that they won’t get a bed if they need one suddenly.
Serious triage doesn’t only prioritise the sickest over the less sick. It also discourages futile treatment for the very sick who are unlikely to benefit from the treatment. Thus, a 90-year-old who maybe otherwise bedridden could be refused admission or someone with an advanced untreatable cancer who develops COVID-19 may be put lower in priority . It’s the same principle of justice applied in the reverse. Executing triage in its truest sense is a big collective leap and needs a certain social sanction. It needs to be perceived to be fair and transparent. The person who gives up a bed does it with the understanding that as and when she really needs it, she will get it. Everyone falls in line towards a greater common good.
In an unequal world, however, the challenges to this idea are immense. In India, a social triage based on class, caste and other hierarchies is everyday practice. Also, whatever the severity of the crisis, it is hard to imagine a determined neutral state implementing a strict triage. Finally, given the current dominance of the private sector, especially in intensive care, triage has to involve state control over the private sector. But if there was ever an opportune moment in this nation’s history to muster courage to implement genuine triage, it is now.
Sanjay Nagral is a Mumbai-based surgeon