Thinking Outside the Crisis: Inequity and Triage

Far from being a “great equalizer,” Covid-19 is exposing the deeper inequities in our healthcare systems and the populations they serve.

This article is part of the Independent’s ongoing series, Thinking Outside the Crisis. Read Robin Whitaker’s introduction here.

By now most of us know that the healthcare systems of specific countries—the United Kingdom, Spain, Italy, and most catastrophically, the United States—are being overwhelmed by Covid-19 cases. Others, like Canada’s, are under considerable stress, and the trajectory for Sweden currently looks bleak.

All these countries are wealthy. For poorly resourced states the outlook is worse.

As of May 11, 2020, there were over four million confirmed Covid-19 cases globally and almost 285,000 deaths. In addition to members of the public, hundreds of hospital workers worldwide—from cleaning staff and paramedics to nurses, social workers, psychiatrists, psychologists, and doctors—have died of Covid-19, contracted while treating the ill. Thousands more have been infected with the virus.

Less known is how unequally Covid-19 illness and death is distributed. Racialized populations in the US—for example, American Indians like the Navajo, African Americans, Latinx—are falling ill and dying at often grossly disproportionate rates. Homeless people, asylum seekers, and others left unacknowledged in legal systems such as trafficked individuals and undocumented migrants are similarly vulnerable. The virus itself may not discriminate, but our economic, social and healthcare systems certainly do. This is not a matter of error, but of the proper functioning of these systems.

Discrimination by Design

Economically, many years of neoliberal cutbacks on public spending have eliminated staffing, beds, and expertise related to pandemics—despite decades of repeated warnings that something like Covid-19 would inevitably occur. Such austerity measures have been imposed on public healthcare systems across the globe. Combined with increasing privatization of hospitals, aged care, clinics, and other aspects of healthcare systems, healthcare priorities have been channeled away from preventive public health measures and towards profit-making areas such as elective surgeries. Faced with the current pandemic, these market distortions have led governments either to do nothing, nationalize the institutions (as Ireland temporarily has done), or cut multi-billion dollar deals for participation (as in Australia). These emergency responses diverted valuable time, money, and effort that should have gone directly into public health.

Public-private market competitions between health systems are one form of healthcare inequity. Beyond these inequities of economic access, there are also inequities of disease. In privatized and two-tiered systems, the treatable are those whose treatment generates a profit. Everything else is irrelevant. Prevention is de-emphasized since it has economic costs but few benefits for individual firms. Public health and pandemic preparedness get defunded. In the US, for example, the Global Health Security and Biodefense unit was eliminated by the Trump government in 2018, and the administration has recently stripped funding from the World Health Organization—the only public health coordinating body with universal reach. As a result, poor people within neoliberal countries have reduced access to needed healthcare, and the situation for global south populations is made markedly worse.

Closer to home, successive governments in Ontario, British Columbia and other provinces have stripped funding from aged care, intensified the casualization of labour, increasingly contracted out long-term care, and otherwise weakened the sector. This erosion of support has directly enabled the emergence of large Covid-19 mortality clusters in specific long-term care facilities. (The Toronto Star reports that 82% of Canada’s Covid-19 deaths have been in long-term care.)

Triaging Discrimination

Inequality is, however, not only a problem at global, regional, and national levels. These systemic problems also emerge locally, even at the institutional level, in the triage decision-making of healthcare workers, regardless of their intentions.

Triage refers to the decision processes by which healthcare workers faced with limited resources determine which patients are entitled to urgently needed medical resources such as drugs, ventilators, and medical staff time. It also determines which staff members get personal protective equipment (PPE) and how much.

Triage is routine and happens everyday in every hospital in the world. It explains why the person who shows up at emergency with a broken finger may wait hours before being treated, while the heart attack victim is rushed in and attended to instantly. Triaging works when there is a small number of patients requiring urgent life support and a lot of patients that are non-urgent. But what happens when there are more people requiring urgent support than there are staff or resources available?

Pandemics put pressure on triage procedures because, when the rate of infection becomes sufficiently high, the number of patients needing urgent life-saving care can overwhelm healthcare staff and facilities. Under such conditions, people who need immediate attention are denied it—not because of malice or poor decision-making, but because healthcare staff can’t provide it. There are not enough ventilators. The drugs have run out. There are 30 beds available, and there are 90 people needing them.

When shortages of this nature are combined with a lack of adequate PPE, the conditions strengthen for catastrophic loss of life. As healthcare staff run out of protective shields, masks, gloves, and other gear, a significant proportion of them become sick with Covid-19 and are forced into isolation. Of that group, a smaller proportion require emergency care. Some of these require intensive care. And some die. No matter where in this population an ill healthcare worker ends up, every healthcare worker lost intensifies the already terrible triaging problems, since each loss is one less person available to treat the ill.

Collateral Harm

The pandemic does not just kill those with Covid-19. All the usual illnesses happen as well. People still have heart attacks, various forms of heart disease, Type 2 diabetes, chronic obstructive pulmonary disease, and cancer. Near fatal accidents continue to happen. Some patients will still require intensive care after an operation. Triage officers have to consider all as they determine who gets intensive care and who is denied it. There is no obvious moral reason to prioritize the Covid-19 patients over the others. Some people who could be saved may be sent to palliative care even though they do not have Covid-19.

The impact of inequality extends still further. In making triage decisions, healthcare workers focus on the survivability of patients. For good reason we are not permitted to discriminate on the basis of age, wealth, gender, disability, or race. Rather, patients are supposed to be scored on some measure—for example, the Sequential Organ Failure Assessment—and those who score well get the resources while those who score poorly should be assigned to palliative care. The moral principle is to save those who can be saved and provide alternative care for those who cannot. People who score poorly will typically have multiple health conditions.

In principle, this approach may sound equitable, but as the social determinants of health play out statistically, triage decision-making inevitably tracks which populations bear the relevant co-morbidities (the additional diseases or other ill-health conditions that exist prior to a specific illness like Covid-19). Impoverished individuals, many First Peoples, African Americans, and asylum seekers are particularly likely to have such co-morbidities as Type-2 diabetes and heart disease, for example, and score poorly for survivability in virtue of this. At a population level they will thus be excluded at higher rates from intensive care resources.

Inequality is violently inscribed on the bodies and minds of the marginalized. Triage scoring systems bring this injustice into stark relief.

As it is, ageism may play some role in triage decision-making in Italy, with triage cutoffs reportedly excluding those over 80, over 70, or even over 65 provided they have the relevant co-morbidities. And some US doctors have been required to score some people with disabilities poorly if their disabilities are of the kind to reduce their likelihood of survival. They may not intentionally discriminate on grounds of disability, but members of the relevant communities are highly likely to receive it that way.

The interaction of neoliberal inequities, Covid-19, and poor management has produced the terrible conditions witnessed in the US, the UK, Italy and elsewhere. For Newfoundland and Labrador and Canada, in the absence of the needed systemic changes, exactly one thing is currently available to prevent similar catastrophes: collective action.

Follow the public health advice. Stay home if you can. But also: make common cause with others to demand public support for housing, income, food, protective equipment and clothing for those who currently cannot.

If the curve increases sufficiently, no medical resources, good intentions, kindness, or love will stop the dying. At a certain point, healthcare workers —and the rest of us—will be left with nothing other than the base human capacity to be a human being and a loving witness to unnecessary deaths.

Richard Matthews is a Newfoundlander, now living in Australia, where he is Associate Professor in the Faculty of Health Sciences and Medicine at Bond University, Gold Coast.

He would like to thank Ms. Emma Woodley for her careful editorial work on this essay, and Dr. Robin Whitaker for her insightful criticisms.

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