Pandemics are known to be the defining “ground zero” for global health. In places experiencing medical emergencies, care is improvised by technologies, vaccines and evidence-based interventions flowing in from around the world. However, between these global models and local dynamics, what everyday forces impede the practice of evidence-based medicine?

Alongside India’s abysmal record of health systems, at a granular level, how are global health treatments and therapeutics failing to heal India? Why is a critical examination of deep-rooted social forces imperative to nuance global public health approaches and to prevent India’s ailing medical systems from further alienating the truly afflicted? I will explore these urgent and interconnected themes through the key global health concept of triage, which is being used in India today, especially during the pandemic.

Emergency medicine is no stranger to the concept of triage, derived from the French word meaning “to sort”. Triage literally refers to the rationing of medical treatments and technologies on the basis of prioritising patients’ severity and likelihood of recovery.

In simple terms, medical triage means that clinicians, hospitals and the state categorise and assign degrees of urgency to the afflicted and their medical conditions in a manner that decides who gets to live by making primary claims to biomedical care.

Historically, the origins of triage lie in European battlefields and colonial theatres of war where it was used to categorise injured soldiers by degrees of wounding. In the postcolonial period, triage has passed through bureaucratised and medicalised regimes of sovereign care to become an important part of global health for managing populations at large, especially in public health emergencies like the Covid-19 pandemic.

The principle of triage is meant to allow both the most acutely ailing patients and the most acutely debilitated medical systems to survive crises though in effect excluding from immediate care those who are not suffering enough or are not resilient enough.

In its idealised form medical triage appeals to empirical assessments of critical care and emergency biomedicine to supercede status-hierarchies, social categories and politics itself. In other words, triage imagines an ostensibly depoliticised and democratic playing field of care in which patients regardless of whether they are from marginalised social and economic groups – and solely on the basis of their afflictions and illnesses – become eligible for impartial therapy.

However, a critical evaluation of triage in everyday practice in India reveals significant contradictions.

Firstly, in public health emergencies of the kind India is currently experiencing the practice of triage risks becoming a spontaneous response to the substantive question of life (and death). Last-minute emergency decisions about who can wait for treatment, who is too sick to survive and who is suffering but not enough to merit immediate care all ethically determine which lives are worthy of being fostered over others.

In the harrowing instances of an oxygen crisis when India’s hospitals have practically become war-zones and vaults of suffering, how medical systems make empirical decisions about triaging care for the critically ill depends on rapid estimates of individual doctors and hospitals amidst the mounting psychological and institutional pressures they are under at the moment and the limits (or lack) of medical technologies and therapeutics materially available.

Unmeasurable concerns

However, from the purview of hospitals, who gets the last vial of a life-saving drug, or the last cylinder of oxygen, or even the last remaining ICU bed – and by the corollary who slips through the cracks of biomedicine’s life-giving embrace – becomes a clinical event, a technical assessment, and not a matter of justice, health rights, and life itself.

Triage maintains the primacy of technical parameters and considerations in which “unmeasurable” concerns about health justice appear unfounded and unethical. Triaging care in medical emergencies thus makes it especially challenging to determine ethical accountability, liability and responsibility even though life and death are outrightly involved.

Anthropologists studying triage in diverse public health emergencies from tuberculosis to HIV-AIDS have also argued that triage problematically advances certain notions of the “authentic suffering subject” and life-deserving patient that match institutional priorities towards life-saving treatment before others.

The challenge of triaging mechanical ventilators, for example, would involve institutional assessments of patients who can afford advanced tertiary care and also have access to exclusive and expensive legal resources in the eventuality of a liability claim and dispute. Triage thus reinforces concrete differences in patient-capacities and privileges for survival despite its aspirations of standardisation within global health regimes.

In the Indian context, who gets to claim health in an emergency is prefigured by who gets to claim health even in everyday situations. Triage by India’s debilitated tertiary-care systems ignores the consequences of meting out emergency medicine in a public health system that is socially and culturally fragmented, and thus excludes the most marginalised from its ambit of care.

The Indian state itself enacts such an unsparing triage by imposing blanket lockdowns and containments without adequately shoring up care for risk-prone groups who are most vulnerable to be excluded from medical systems in times of dramatically diminished health capacities; such people are unable to lay claim on biomedicine because in reality they are unable to lay claim on the social world – a biopolitical fact that triage obscures and obfuscates.

Secondly, and more importantly, to examine the troubles with global health triage, we need to move away from moments of crisis to the minutiae of the everyday. In the Indian context, we must ask, how capacious is the notion of medical triage where social privilege, affiliations of caste and class, bureaucratic networks and economic entitlements determine access to hospitals for a few while quarantining hundreds of thousands from even basic healthcare?

Are those from India’s lowest caste and class groups who routinely perform care functions, like sanitation workers, ambulance drivers, mortuary and cemetery workers, paramedical staff and last-mile caregivers given priority when tertiary hospitals triage the afflicted based on technical needs assessments, costs of care, clinical utility, survivability, and resilience? Are members of such groups ever considered to be “suffering enough” by the rationing mechanisms of medicine?

Ironically, biomedical and biopolitical processes that endorse some lives over others – not only in emergencies but even in the everyday – make it easier for the virus to claim victory.

Excluding the marginalised

Furthermore, an inordinate focus on triage as an evidence-based practice by emergency medicine and the state diverts crucial attention away from underlying forms of structural and social triage in India, which have longitudinally debilitated the health of particular groups based on caste, ethnicity, gender and class.

Social stratification in the Indian context performs a primary and pernicious form of triage by prescribing humiliating and chronically harmful labours, livelihoods and living-conditions for India’s most marginalised. Dalits and lower-castes have for the same reasons lived with compromised immune systems, bodies maimed by malnutrition and afflicted by aggregated toxic exposures over their life-course. A global health system that encourages medical triage without adequately accounting for social triage is bound to fail practically in meeting its objectives of saving and improving the quality of life for all.

The problem at the heart of a health emergency like Covid-19 is thus not the collapse of emergency medicine but of public health itself. What we need more than ever is an overhauled public health model that empirically and ethically takes stock of entrenched social disparities and works to remedy the weak health systems caused by them.

While global demands for public health with science at its core – as was recently made by Lancet – are urgent, inattention to the social forces that shape global public health in India will continue to produce biomedicine and health as weapons for the privileged against those whose forms of suffering and debility are unmeasurable and therefore erasable from the social record of care.

The biggest lesson India can learn from the present crisis is that a strong, socially attuned public health system must be in place to ensure that medical triage and global health do not exacerbate India’s deep rooted social inequalities.

Nikhil Pandhi is a doctoral candidate in medical and cultural anthropology at Princeton University. He ethnographically researches the socio-cultural determinants of health in India.