Two Trains, Eighty-Four Injured: Health When Everything Goes Wrong

This is actually a global problem, not an Indonesian one specifically.

Mass casualty events overwhelm health systems that are dimensioned for normal daily demand.

The question is how prepared any given place is to surge.

Exactamente.

Exactly.

En medicina de emergencias, hay un concepto que se llama triage.

In emergency medicine, there is a concept called triage.

Cuando llegan muchos heridos al mismo tiempo, los médicos tienen que decidir muy rápido quién necesita atención inmediata, quién puede esperar, y quién ya no tiene posibilidades de sobrevivir.

When many injured people arrive at the same time, doctors have to decide very quickly who needs immediate attention, who can wait, and who no longer has a chance of surviving.

Es una decisión terrible.

It is a terrible decision.

I've reported from field hospitals in conflict zones, and the triage question is genuinely haunting.

You're not choosing who lives.

You're choosing where to spend the next thirty minutes.

The math feels inhuman but it saves more lives than ignoring the math would.

Y ese sistema de triage requiere entrenamiento específico.

And that triage system requires specific training.

No todos los médicos en Indonesia tienen ese entrenamiento.

Not all doctors in Indonesia have that training.

En los hospitales grandes de Yakarta, sí.

In the large hospitals in Jakarta, yes.

Pero hay muchos hospitales más pequeños en todo el país donde los médicos no están preparados para estos momentos.

But there are many smaller hospitals across the country where doctors are not prepared for these moments.

There's a historical piece to this that I find genuinely interesting.

Indonesia's modern healthcare system is really only about sixty years old in any meaningful sense.

The Dutch colonial administration provided almost no health infrastructure for the local population.

It was built for Europeans.

Sí.

Yes.

Cuando Indonesia se independizó en 1945, tenía muy pocos médicos locales, muy pocos hospitales para la gente común.

When Indonesia became independent in 1945, it had very few local doctors, very few hospitals for ordinary people.

El país empezó casi desde cero.

The country started almost from zero.

Y ahora tiene más de doscientos setenta millones de personas.

And now it has more than two hundred and seventy million people.

Es el cuarto país más poblado del mundo.

It is the fourth most populous country in the world.

Two hundred and seventy million people spread across more than seventeen thousand islands.

The logistical challenge of building a coherent health system for that geography is almost incomprehensible.

Y, sin embargo, Indonesia ha hecho progresos reales.

And yet, Indonesia has made real progress.

La mortalidad infantil ha bajado mucho en los últimos cuarenta años.

Child mortality has fallen a lot in the last forty years.

La esperanza de vida pasó de unos cuarenta y cinco años en los años sesenta a más de setenta y tres años ahora.

Life expectancy went from about forty-five years in the nineteen sixties to more than seventy-three years now.

Es un cambio enorme.

It is an enormous change.

That's a number that deserves to be said clearly.

From forty-five to seventy-three.

In sixty years.

That's not a small bureaucratic improvement;

that's a transformation in what it means to be born there.

Pero aún hay problemas serios.

But there are still serious problems.

Un problema muy importante es el número de médicos.

A very important problem is the number of doctors.

Indonesia tiene aproximadamente cuatro médicos por cada diez mil personas.

Indonesia has approximately four doctors for every ten thousand people.

España, por ejemplo, tiene unos cuarenta.

Spain, for example, has about forty.

Estados Unidos tiene unos treinta y cinco.

The United States has about thirty-five.

La diferencia es muy grande.

The difference is very large.

Four per ten thousand.

And when you get a train crash with eighty-four injured, those four suddenly become the system's entire front line.

You feel that ratio in your bones very quickly.

Y el problema es que Indonesia forma muchos médicos, pero muchos de ellos se van a las ciudades.

And the problem is that Indonesia trains many doctors, but many of them go to the cities.

Los médicos jóvenes no quieren trabajar en zonas rurales porque los sueldos son más bajos, las condiciones son más difíciles, y las oportunidades profesionales son menores.

Young doctors do not want to work in rural areas because the salaries are lower, the conditions are harder, and the professional opportunities are fewer.

That's the brain drain problem, but inside a country rather than between countries.

You train the people, and then economic gravity pulls them toward the center.

It happens in the American south, it happens in rural Spain, it happens everywhere.

Exacto.

Exactly.

Y Indonesia intentó solucionar esto con un programa que obliga a los médicos nuevos a trabajar un año en zonas rurales o remotas antes de poder especializarse.

And Indonesia tried to solve this with a program that requires new doctors to work one year in rural or remote areas before they can specialize.

Se llama internado.

It is called internship.

Pero muchos médicos buscan maneras de evitarlo.

But many doctors look for ways to avoid it.

You can legislate presence but you can't legislate commitment.

If someone is counting down the days to leave, the quality of care they're delivering in month eleven is not the same as in month one.

Hay otro aspecto que me parece muy importante hablar.

There is another aspect that I think is very important to discuss.

Cuando hay un accidente grande como este, la respuesta inicial depende mucho de la gente normal, no de los médicos.

When there is a big accident like this, the initial response depends a lot on ordinary people, not on doctors.

Los primeros en llegar a un accidente de tren son otras personas del tren, gente de la calle.

The first to arrive at a train accident are other people from the train, people from the street.

Y muy pocos saben hacer reanimación cardiopulmonar, o cómo mover a alguien con una lesión en la columna vertebral.

And very few know how to do CPR, or how to move someone with a spinal injury.

That's a crucial point.

Studies from high-income countries show that survival rates in cardiac arrest double when bystanders intervene correctly before emergency services arrive.

The few minutes before the ambulance get there are often the ones that determine the outcome.

Sí.

Yes.

Y en Indonesia, como en muchos países en desarrollo, la educación en primeros auxilios no es obligatoria en los colegios.

And in Indonesia, as in many developing countries, first aid education is not mandatory in schools.

No es parte normal de la vida.

It is not a normal part of life.

En Alemania, por ejemplo, aprender primeros auxilios es un requisito para obtener el carné de conducir.

In Germany, for example, learning first aid is a requirement to get a driving license.

En muchos países nórdicos, los niños aprenden reanimación cardiopulmonar en la escuela.

In many Nordic countries, children learn CPR at school.

There's something almost political about that gap.

The decision to teach CPR in schools is cheap, it is scalable, and it saves lives.

The reason it doesn't happen in many places isn't lack of knowledge.

It's prioritization.

Y también es un problema de cultura.

And it is also a problem of culture.

En muchos países, la gente normal no quiere tocar a una persona herida porque tiene miedo de hacerlo mal, o tiene miedo de problemas legales después.

In many countries, ordinary people do not want to touch an injured person because they are afraid of doing it wrong, or they are afraid of legal problems afterward.

En España también pasa esto, aunque tenemos leyes que protegen a las personas que ayudan de buena fe.

This happens in Spain too, although we have laws that protect people who help in good faith.

Good Samaritan laws.

The United States has them too, though they vary by state, which, given that it's the United States, should surprise no one.

Fletcher, aquí quiero hablar de algo que me parece fascinante.

Fletcher, here I want to talk about something I find fascinating.

Este accidente pasó en un lugar muy urbano, muy moderno en muchos sentidos.

This accident happened in a very urban, very modern place in many ways.

Bekasi tiene centros comerciales gigantes, tecnología, internet rápido.

Bekasi has giant shopping malls, technology, fast internet.

Pero cuando pasó el accidente, el sistema de salud mostró sus límites muy rápidamente.

But when the accident happened, the health system showed its limits very quickly.

That's the paradox of development, isn't it.

The visible layer of modernity, the glass towers, the fast food chains, the 5G, it can be completely disconnected from the depth of infrastructure underneath.

And healthcare is one of the deepest layers.

You don't see it until you need it.

Muy bien dicho.

Very well said.

Y la pandemia de COVID-19 demostró esto en todo el mundo, no solo en Indonesia.

And the COVID-19 pandemic showed this across the world, not just in Indonesia.

Países que parecían muy preparados, con hospitales modernos, fallaron en momentos de crisis.

Countries that seemed very prepared, with modern hospitals, failed in moments of crisis.

Y países que tenían menos recursos a veces organizaron respuestas muy eficientes porque ya tenían experiencia con emergencias de salud.

And countries with fewer resources sometimes organized very efficient responses because they already had experience with health emergencies.

Cuba is the example that always comes to mind.

Terrible economy, very sophisticated primary care infrastructure, and a public health response to disasters that consistently outperforms countries ten times wealthier.

The money and the system don't always move together.

De acuerdo.

Agreed.

Y Indonesia tiene capacidad.

And Indonesia has capacity.

El país tiene médicos inteligentes, tiene hospitales que funcionan.

The country has intelligent doctors, it has hospitals that function.

Lo que no tiene es suficiente coordinación entre los diferentes niveles del sistema cuando hay una emergencia masiva.

What it does not have is enough coordination between the different levels of the system when there is a mass emergency.

La comunicación entre los primeros respondedores, los hospitales, y las autoridades locales es a veces muy lenta.

The communication between first responders, hospitals, and local authorities is sometimes very slow.

Coordination is the word I was going to land on too.

In Jakarta's 2018 earthquake and tsunami response, the failure wasn't resources exactly.

It was command structure.

Who calls whom, who has authority to redirect ambulances, who decides when a hospital is full.

When that's unclear, people die in parking lots waiting for a decision.

Y eso es algo que Indonesia está intentando mejorar.

And that is something Indonesia is trying to improve.

Después de los terremotos de Lombok y Palu en 2018, el gobierno creó nuevos protocolos de emergencia médica.

After the earthquakes in Lombok and Palu in 2018, the government created new emergency medical protocols.

Pero implementar esos protocolos en todo el país, con diecisiete mil islas y cientos de lenguas diferentes, es un trabajo enorme.

But implementing those protocols across the country, with seventeen thousand islands and hundreds of different languages, is an enormous task.

Right.

And here's what this week's accident in Bekasi is, beyond the tragedy of it.

It is a stress test.

Not a scheduled one, not a simulation.

A real, unannounced stress test of whether the improvements since 2018 have actually reached the system.

We'll see what the reporting shows in the coming weeks.

Oye, Fletcher, hay algo que dije antes que quiero explicar un poco más, porque creo que es útil para los oyentes.

Hey, Fletcher, there is something I said earlier that I want to explain a little more, because I think it is useful for the listeners.

Usé la palabra "sanitario" varias veces en nuestra conversación, y sé que en inglés esa palabra tiene un significado diferente.

I used the word 'sanitario' several times in our conversation, and I know that in English that word has a different meaning.

Ah, yes.

I was going to ask you about that actually.

In English, 'sanitary' basically means clean, hygienic.

But the way you were using it, it seemed to mean something else entirely.

Exacto.

Exactly.

En español, 'sanitario' como adjetivo significa relacionado con la salud o la medicina.

In Spanish, 'sanitario' as an adjective means related to health or medicine.

'Los trabajadores sanitarios' son los trabajadores de la salud, como médicos y enfermeras.

'Los trabajadores sanitarios' are healthcare workers, like doctors and nurses.

El 'sistema sanitario' es el sistema de salud.

'El sistema sanitario' is the health system.

También, 'un sanitario' como sustantivo masculino puede ser simplemente el váter, el inodoro.

Also, 'un sanitario' as a masculine noun can simply be the toilet.

Así que el contexto importa mucho.

So context matters a lot.

So if I walked into a hospital in Madrid and asked a nurse where the sanitario was, she might point me toward the bathroom rather than her supervisor.

That is exactly the kind of linguistic trap I would walk straight into.

Sí, probablemente.

Yes, probably.

Y lo interesante es que los dos significados vienen de la misma idea original: la palabra viene del latín 'sanitas', que significa salud.

And the interesting thing is that both meanings come from the same original idea: the word comes from the Latin 'sanitas', which means health.

La higiene y la medicina eran parte de la misma cosa para los romanos.

Hygiene and medicine were part of the same thing for the Romans.

Es una palabra con mucha historia dentro.

It is a word with a lot of history inside it.

Sanitas.

Health.

Which is also where 'sane' comes from in English.

A healthy mind.

So the Romans weren't entirely wrong to bundle it all together.

Though I suspect the next time I ask for the sanitario, I'm still going to end up somewhere I didn't intend.

Con tu nivel de español, Fletcher, sí.

With your level of Spanish, Fletcher, yes.

Pero sabes qué, si preguntas por los servicios, por el baño, o por el aseo, también llegas al mismo sitio.

But you know what, if you ask for 'los servicios', 'el baño', or 'el aseo', you also get to the same place.

Muchas palabras para el mismo lugar.

Many words for the same place.

Algo típicamente español, en mi opinión.

Something typically Spanish, in my opinion.