Triage beyond the clinic
Résumé
Triage is associated with almost every intervention by major actors in global health, who repeatedly insist on their priorities and the need to make ‘tough’ choices even if it is difficult to legitimize priorities broadly perceived as opposing a comprehensive right to health. This chapter starts with the structural existence of triage. Systemic prioritization may operate through diverse and shifting metrics and means. It may be a matter of choosing specific diseases, of selecting techniques and interventions, of targeting preferred social groups. The basic argument is that the transition from international public health to global health has resulted in deep changes in the modes of triage. These changes affect all of the parts of the process: its core categories, the institutions and experts in charge, the tools involved. Political triage has been marginalized for the benefit of economic triage. In the 1960s and 1970s, post-colonial nation-states, their bureaucratic apparatuses and their public health experts defined “basic,” “essential” needs through processes that mobilized public health statistics. From the late 1980s onward, global health shifted the basis of authority from the political to the economic and technocratic. Nowadays triage is thought of as a management problem. An entirely new cadre of personnel has grown out of this change, as well as new tools and data—such as medico-economic evaluation, pilot-studies, operationalization trials, and recording and audit processes that the different sections in the chapter explore. The chapter also sheds light on the tensions between local political triage and global economical triage.