Risk and triage

What is Triage?

Typically, this term appears in a medical context where it refers to the process of determining priority of treatment based on the severity of a condition. For example, a hospital emergency room may have multiple patients to treat, and its triage that helps determine how to prioritize their treatment. Urgent and severe problems are dealt with first, and so on down the list of patients.

This would probably strike most people as “common sense” – it is clearly stupid to treat someone’s tooth ache while another patient with multiple gunshot wounds dies in the waiting room from lack of attention. Importantly, however, not every situation is so clear cut. Sometimes a patient with an urgent medical problem may not obviously present that way, while someone with a lesser issue can make a lot of noise demanding urgent attention (a tooth ache is a good example – exceptionally painful at times, but rarely life-threatening. The identification and classification of risk is, therefore, just as critical an aspect of triage as the ensuing prioritization that it informs. In other words, we need a way to identify the “quiet” but high-risk patients, just like we need a way to identify the high-risk threats that may not obviously present themselves, like someone screaming about a toothache or something with a gaping chest wound.

[Editor’s comment: The other part of triage which you haven’t mentioned is that patients who are urgent but too far gone are not treated – what are the sustainability parallels? Do we need to jettison certain causes in favour of those that are still saveable?]

The point here is that triage needs two things to work well: it’s not just about ranking threats, it’s also about identifying them in the first place – as many as possible that might be of relevance or importance.  A good classification and identification scheme can help us in the more uncertain situations, when multiple high-priority issues present simultaneously. One can easily argue this is the case in sustainability, where climate change, resource constraints, economic equality, human rights, peace and justice, and other issues all present as equally urgent (and frustratingly, are often interrelated – making it harder to separate and then prioritize just one).

The UN Sustainable Development goals exemplifies, quite well I think, how we have frameworks already attempting something like the first half the work of triage – identifying threats. It’s not quite framed that way, but many can be read out of each goal. Eliminating poverty, for example, reduces the risk of harm at a personal level, and reduces the risk of broader societal disorder – and the reason we want to do this is, partly, to reduce such risks. The UN even demonstrates thinking “beyond the grass ceiling” and include issues like economic inequality, justice and peace, and human rights. What the SDGs lack, however, is an explicit risk-based focus, and any kind of serious ranking or triage. In a world of finite time and other resources, should we focus on SDG #1 or #10? Which one minimizes potential risks the most? Clearly, the framework isn’t that useful overall for a triage approach.

Now, perhaps, we need to begin the work of sorting out what’s most important from lists like these. We need something as accessible and well-supported as the SDGs, but we need it ranked, so that we can prioritize. This won’t be easy, since developing a criteria to rank these things would be immensely difficult and complex, and because as said earlier, these issues often interrelate. Despite the challenge of this task, we must take it on. Without a roadmap of prioritized risks, we are blindly hoping the things we focus most on (like climate change) are indeed the biggest threats. It’s fair to question if this focus comes with a cost.

Why can’t we do both?

We can do two things at once, of course. Issues can be “equally important” too. Just as they are interrelated. But we cannot pretend we have infinite resources to tackle sustainability challenges either. Money is limited. People’s attention spans are limited. The time people can devote to the cause actively and consciously is limited. Time, especially, is limited.

It is within the context of these constraints that a simple truth emerges: we need some level of focus here. We can’t just say “it’s all important” and proceed haphazardly, according to our own interests and agendas. Do that, and there’s a real risk we run out of time to fix certain problems in an optimal way. This truth is as uncomfortable as it is obvious – it implies there will be sacrifices; issues deprioritized along the way. A good example of this playing out, as I write these words, is the conflict between quarantine protocols protecting public health, and people’s right to protest. The clash between the Black Lives Matter movement and the restrictions of COVID-19 illustrate well, the kinds of difficult conversations ahead. In the Apeilicene, we are likely to see these situations with increasing frequency, as time-sensitive threats arise and demand extraordinarily difficult choices of us.

Similarly, we can’t expect that the current focal points themselves aren’t the product of political agendas and self-interest. If triage enables progression via focused prioritization, then it demands sacrifice as I’ve said. If sacrifices are required, it’s overwhelmingly more likely to be demanded of the powerless by the powerful. This perspective sheds some light on the landscape of global sustainable development. Often it is rich, industrialized nations pressuring less-wealthy countries to leapfrog coal and jump into more expensive solar – for example. In other words, the powerful expecting the powerless to do the heavy lifting.

What about root causes?

This is an issues-oriented approach, clearly. We might question why we aren’t identifying whole systems as problems. Capitalism, consumerism, and so on. The guy in the emergency room with heart attack symptoms isn’t just there because of his individual circumstances. There are larger, structural forces like globalization, modernism, reductions in manual labour, and consumerism that likely shaped his individual circumstances and the choices he could exercise.

But triage is not about root causes or systemic, structural change. It is what you practice in the emergency room. When someone’s heart is about to stop, it’s that immediate crisis you focus on, not systemic change.

Explaining the lack of triage in mainstream sustainability

In contrast with a triage approach to sustainability, triage in health care is not a peripheral concern – it is a core practice supported by years of research and used in basically every medical institution around the world. Why then, in sustainability, is this same approach not taken?

One possible explanation is that focusing on risks; on problems and challenges, often places a negative frame on a given issue, making it harder to identify potential opportunities. Similarly, focusing on risks can present challenges for communicating sustainability. Research shows that fearful messages cause disengagement, apathy, and a sense of hopelessness and incompetence. Continued exposure causes most people to “tune out the messages and move on to other, more pleasant concerns”[1].  Despite its obvious importance, a threat-based approach to sustainability clearly presents some challenges and considerations, and in looking at some examples of threat-based models, we’ll start to see the devil, as always, is lurking in the details.

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Footnotes

[1] Robertson, M. (2017). Communicating Sustainability. New York: Routledge.

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