Just about every schoolchild learns that Napoleon Bonaparte was a small man. But few know that he cast as large a shadow over the history of medicine as over the nature of warfare. That’s because his surgeon-in-chief in the Napoleonic Wars, Dominique Jean Larrey, transformed how wounded soldiers are cared for.
His innovation — triage — is still used today in battlefield medicine and responses to public health crises. Yet it needs to be reimagined in how it is being applied to fighting the Covid-19 pandemic.
Triage was coined from the French word “trier,” meaning to sort. It helps prioritize the treatment of people who are injured or ill. It directs scarce medical resources to those who are expected to survive with urgent care rather than to those likely to recover on their own or those unlikely to live even if treated. It is a sound practice during military campaigns and natural or human-made disasters when resources or medical staff are in short supply. But it is important to understand when triage is warranted, when it is not, and its limitations.
I first faced triage after the Vietnam War as a medical volunteer in the Khao-I-Dang refugee camp at the border between Thailand and Cambodia. Our team cared for survivors of the Cambodian genocide perpetrated by the Pol Pot regime in the midst of ongoing military skirmishes.
When too many injured people made their way to our camp, we had to resort to triage. Those with hopelessly mortal wounds were made comfortable. Those more likely to survive received trauma care. Many were children, suffering from injuries and diseases easily treated in a conventional medical setting but not so in a refugee camp. Children with cancer, for example, did not survive. I remember one child with leukemia who would have recovered if diagnosed elsewhere.
Triage calls for doing what is possible in the situation you are in.
During the Covid-19 pandemic, witness the incomprehensible decisions health care workers have had to make when hospitals become overcrowded with Covid-19 patients and there aren’t enough beds or ventilators for them. That’s when triage must be employed.
In the United States, as well as in the European Union and European Economic Area, Covid-19 vaccines are now being triaged. Those who are most vulnerable and most likely to benefit get vaccinated first. Shots are delayed for those who are likely to survive Covid-19 even if they become infected.
But vaccination triage needs to be viewed through a broader lens.
When first envisioned, triage helped manage resources in a single military theater. In a pandemic, it must be reimagined because what happens in one country can affect all of the others.
Consider the spread of Covid-19 variants. New strains of SARS-CoV-2, the virus that causes Covid-19, were first reported in the United Kingdom, South Africa, and Brazil. These new strains, which appear to be more infectious than the original, have spread around the world, and other variants are being detected all the time.
To continue spreading and mutating, the virus must replicate in hosts who are not immune. Stopping it from replicating — and mutating — means protecting people everywhere, not just in one country or a few. If the virus continues to spread, it will continue to mutate, possibly leading to variants that can evade the existing vaccines or resist available treatments.
The United States and other wealthy countries are not yet acting on this fact. The richest nations are looking out for themselves and holding onto large stocks of vaccine that could be shared with other nations in need. This approach ignores where the virus is lurking and who is at highest risk. Continuing down this path would endanger all nations, regardless of income.
We need a sprint to vaccinate everyone, not just people in wealthy countries, before variants take hold. Vaccine nationalism — when countries sign agreements to secure vaccines for their citizens alone — limits access for others. This strategy threatens to extend the pandemic rather than end it.
The World Health Organization’s director-general advocates for the COVAX initiative. It accelerates development, production, and equitable access to Covid-19 tests, treatments, and vaccines to all countries. This will reduce Covid-19-related disparities around the world.
Everyone has a stake in the COVAX objective. Few will dodge Covid-19 personally or have it bypass their family, friends, or communities. That’s reason enough to put in place the right measures to combat the Covid-19 threat: global vaccination.
Ethan Dmitrovsky is a physician-scientist, president of Leidos Biomedical Research, and director of the Frederick National Laboratory for Cancer Research.
