Silent Triage: Public Health decision-making beyond prioritisation

Abstract

The COVID-19 pandemic has influenced clinical care and health service provision in low-income and middle-income countries. Besides having no timely access to routine vaccination, services for non-SARS-CoV-2-related health conditions faced major restraints due to pandemic countermeasures. Serving as an example, outpatient visits, HIV tests conducted and the administration of the Diphtheria-Tetanus- Pertussis (DTP3) vaccine decreased significantly in Kenya. In Ethiopia, Nigeria and Burkina Faso over half of the essential health services have been affected by limitations in access, referrals, prevention and health promotion activities. Schools were closed, and Kenyan girls were twice as likely to become pregnant before graduation than before SARS-CoV-2.<br> Even though it was already stressed in early 2020 that maintaining services for, for example, reproductive health is ‘not a luxury’, avoiding contagion with SARS-CoV-2 became de facto the primary consideration in many areas of care. Health and health-related needs were assigned certain importance, according to their felt urgency or because of the availability of resources in time, space or personnel. Many individuals’ non-SARS-CoV-2-related medical interests were subordinated to this one public (health) interest. Hence, we argue that the widely visible disruption of health services, and obstructed access to clinical care and Public Health programmes, as well as the suspension of other health-related measures such as WASH and nutri- tion programmes, could be considered a form of ‘triage’. However, while conventional triage is a conscious decision with an imme- diate impact mainly on already known individuals, we introduce the term ‘Silent Triage’, pointing out the unconsciousness and passiveness with regard to most persons concerned. Whereas conventional triage is highly needed to optimise overall health outcomes for a given group of individuals, Silent Triage may create collateral damage such as malnutrition among school children or more late-stage diagnosis of cancer in the future.