By Landon Yarrington
University of Arizona
When we think of triage, most of us probably imagine packed emergency rooms and congested hospitals; or we may envision throngs of the not-that-sick seated in waiting rooms, quietly suffering until it’s their turn to be treated. Alternatively, we might also think of the drama of a battlefield hospital, scenes that MASH popularized in the years following the Vietnam War. For whichever example one might imagine, it’s seldom the case that we consider triage as a process of establishing order. Rarer still is the thought that triage is a culturally mediated process.
Triage comes to us from the French verb trier, which means to sort or sift out, as in sorting and sifting dried coffee. Triage earned its contemporary colloquial definition not from agriculture, however, but from the battlefields of the Napoleonic Wars. There, Dominique Jean Larrey, Napoleon’s chief surgeon, implemented an original system of identifying and categorizing wounds according to their severity (Skandalakis 2006). Unlike today’s system, where life-threatening conditions get higher priority for treatment, Larrey’s model prioritized those whose wounds were most likely to be healed. The system functioned less to save lives and more to put soldiers back on the lines.
Today, whether we realize it or not, we use the triage categorical system in contexts well beyond the medical field. From business meetings to daily household purchases, we are essentially performing triage.
As a medical decision-making process aimed at maximizing life and minimizing risk through a dynamic formula of patient needs plus existing resources plus available personnel, compounded by the timeliness of the decisions themselves, triage necessarily simplifies a constellation of moral and ethical ambiguities. Triage seemingly provides an objective, scientific way to evaluate such situations without bias and independent of context. It is this logic of triage—the claim of an objective, non-arbitrary way of arranging, prioritizing, and canalizing different sets of competing needs—that is applied in a variety of contexts.
This essay argues that, during and after disaster scenarios, vulnerability is often assessed and responded to using the logic of triage. This use of triage in responding to and assessing vulnerability was particularly evident during and after the Haitian earthquake.
When the quake struck around 5:00 pm, I was conducting preliminary fieldwork in Port-au-Prince. Before nightfall, the city seemed to be operating according to the logic of triage. I was helping to move wounded people from their houses into an empty lot when I decided to go out to the main street and find some help, thinking the police or the United Nations would send aid. It was then that I realized the whole city was devastated (or “tout Ayiti kraze!” in the words of one Haitian police officer). I went again 30 minutes later (by then over 200 people had gathered in the open space), and this time I spotted a massive U.N. convoy passing with bulldozers, supply vehicles, and two trucks full of troops. Surely with this equipment and manpower I could get some help, I thought. But I was then informed they were on their way to the Hotel Christophe—the U.N.’s administrative headquarters in Haiti—which had flattened everything and everyone inside. In this space of competing needs, who gets served first, and why?
The next day, after making my way to the U.N. logistics base at Toussaint Louverture (the country’s only international airport), I witnessed another triage event. Around noon, the authorities decided to allow wounded Haitians in for on-site treatment or transport to hospitals in Miami. I was confused to learn that they were only allowing those people who had some familiarity with English into the compound. A Canadian medic told me that since English was the operational language (as opposed to French, which is the official language of the U.N.), they could faster and more efficiently treat Haitians who knew some English. When Creole-speaking Haitians were finally let in they were met by exhausted staff, depleted supplies, and second-class treatment.
From the U.S. military’s subsequent takeover of the international airport to the many “cluster group” meetings the U.N. organized to distribute food, water, and tents, the logic of triage was almost always employed. And when I returned to Haiti in September 2010, I saw the logic of triage unfold all over again in the responses to outbreaks of cholera.
Humanitarianism and humanitarian aid not only operates by the logic of triage; it cannot exist without it. For humanitarian action to be possible, order must first be established. But how is order created? Who has the rights to establish order, and by whose categories? When a disaster hits, how are needs constituted and how is humanitarian assistance mobilized? These are questions that may be best addressed through an ethnography of triage.
In the case of Haiti, the logic of triage created a doctor/patient relationship between the various humanitarian actors and the target population. Under these circumstances, the expertise of humanitarian actors can mask power disparities and cultural biases as professional objectivity in categorizing needs. Following this, triage events provide a powerful frame of analysis for how authority is established within the structure of humanitarian aid.
If we understand triage as a system dedicated to imposing order according to immediate needs, then triage can never be independent of context, for it is the specific, localized social and cultural context of a disaster from which needs receive their substance. This feature of triage decision-making makes it impossible to base medical decisions on medical criteria alone, for instance, and invites other, non-medical factors to infiltrate the decision-making process. The result is that triage will always be culturally mediated and open to social, economic, and other various influences. Seen in this way, humanitarianism, as the first step or phase of a presumably longer transition including recovery and reconstruction, is open to the same critiques made of disaster capitalism (Gunewardena and Schuller 2008).
For applied anthropologists working in disaster contexts, there is value in highlighting and identifying these triage events. Some decision-making must necessarily transpire “on the fly,” in the moments immediately after the dust settles, while other sets of decisions will be made further away from the immediacy of a disaster event. I would like to suggest that what we call the “aftermath” of a disaster is nothing more than a series of triage events. In this way, framing disasters in terms of triage events provides a valuable tool for understanding the assessment of vulnerability and power dynamics visible in disaster situations.
Gunewardena, Nandini and Mark Schuller, eds. 2008. Capitalizing on Catastrophe: Neoliberal Strategies in Disaster Reconstruction. Plymouth, UK: AltaMira Press.
Skandalakis, Panagiotis. 2006. “’To Afford the Wounded Speedy Assistance’: Dominique Jean Larrey and Napoleon.” World Journal of Surgery 30:1392-1399