Photo: Reuters
Photo: Reuters

What lies between trust and the trustworthy

Why may a municipal hospital be better than a private one with more amenities? Answers emerge when accidents happen, and convention is questioned

A very long short: Early last week, the family driver met with a tragic episode. He fainted on the wheel and lost control of the car. Passing motorists figured something is the matter and attempted to cordon it off. A passer-by ran beside it, opened the door to get in, pulled the handbrake and got it to halt. Because the episode happened close to home, an acquaintance figured it is my car and I was promptly informed. 

On getting there in a few minutes, it was clear something was dreadfully wrong. The 37-year old sounded incoherent and was hallucinating. All accounts from witnesses to the episode suggested he had just had an epileptic seizure. He had to be pinned down and taken to a hospital right away. With help from strangers and an obliging taxi driver, he was rushed to the nearest hospital. 

En route to the place, calls were placed to friends in the neurosciences. Basis their prognosis over the phone and my limited understanding of the symptoms, a few outcomes looked possible. It could be anything from a haemorrhage in the brain triggered by high blood pressure or a seizure triggered by some kind of encephalitis. To zero in the real cause, medical protocol insisted first be sedated to rein in the violent behaviour, an MRI be conducted, and a few life-saving drugs be pumped in. Else permanent impairment or even death looked imminent.

On getting to the casualty ward, I didn’t think it pertinent to describe at length all of what transpired—but quickly summarise whatever happened and suggest he be restrained first and that urgent protocols as mandated when such behaviour is demonstrated be administered. I was stared right back at and told: “He looks perfectly all right to me."

Even as the doctor said that, he got up and ran away from imaginary demons into oblivion. The security let him pass. They heard the doctor pronounce him hale and hearty. I yelled at the intensivist for thinking me an idiot. “I know what I’m talking about," went unheard. But she looked right through me. 

Much later I was told she felt mighty offended. What protocol to follow is something she decides and isn’t dictated by anybody. I certainly didn’t look the kind who could offer informed advice—unkempt in a worn-out t-Shirt, sloppy shorts, stubble a few days old on my face, and bathroom slippers on my feet.

Just when it was time to lodge a man-missing complaint with the police, he reappeared on the horizon. This time, looking lost, dishevelled, and talking to ghosts. Much drama and another long story followed that lasted until mid-night when I finally sunk into bed, exhausted after all of what had transpired. 

In hindsight, the sanest piece of advice I received during the day was that he be taken to KEM Hospital in Mumbai. When I was first told that though, my reaction was “Any place, but not there". How terribly, terribly wrong I was would be evidently only much later.

The first reaction KEM Hospital evoked from me is a uniform one that the “privileged" living in metropolitan cities like Mumbai feel. It has much to do with that this is a hospital managed by the Municipal Corporation of the city and owes its allegiance to the government. And the government, the privileged believe, have a track record of mismanaging pretty much everything. But because there was no resort or resource left with after much adventure through the day, it was the last option. 

KEM Hospital is like a parallel universe. An altogether different system that operates at a pace and rhythm that makes no sense to those who live outside of it. Throbbing with thousands of people of all kinds, at first glance, it looks like a war zone. Casualties are brought in every minute, their misery intact, some howling in pain, others waiting to die, many accompanied by wailing relatives, others by a harried police constable, even as the medical and para-medical staff work against the odds. It is inevitable then that they have neither the time or the inclination to engage in polite talk. Everybody looks rushed and sounds brusque.

With a convulsing man though, I imagined some latitude may be offered to get ahead of the others so that this creature, whose misery I was holding, could be offered some immediate relief. Instead, I was asked to stop being stupid, shut up and wait in a queue—because there were others whose misery looked greater. Broken heads, torn limbs, flowing blood, crying children, everybody looked and sounded even more miserable and desperate. 

It was soon evident why the professionals at work there look as rushed and sound as brusque as they do. They take calls every minute, every hour, every day, on their feet in harsh conditions. It can break down the hardiest of souls. There is no room for emotion. If any such thing be felt, it can be drowned elsewhere—but not here. There are real people that must be attended to. All of them must be paid equal attention. Time is at a premium. All help is appreciated, but not acknowledged. This is an ecosystem that has a mind of its own and gets on with life on its terms. 

A little while later, it was time for one of the overworked doctor to now look at the cranky mess of a man with me and his wailing wife as well in tow. The physician quickly heard me out and had no problem either with noting my opinion. He finally weighed all the evidence with a counterpart in a matter of a few minutes, so a call may be taken. I heard them quietly confer with each other quickly: “Herpes Simplex?" one wondered. 

Over the years, I have gotten to know enough about this strain of the virus. That compelled me to butt in and suggest that while the clinical symptoms may suggest that, the diagnosis can be misleading in my experience, and a deeper probe may be needed. They didn’t roll their eyes or look at me suspiciously. Instead they jotted it down on the case paper, agreed to hospitalise him right away, and investigate some more. Unlike the earlier place, there was no time or room for egos to clash. That was it. My job, he said, is done. I was asked to step aside so the system can take over to do whatever it thinks is appropriate. 

What system? I thought I couldn’t see anything, except chaos. Just then out of where somebody emerged out of someplace and directed me to another official, so my statement can be recorded for the police to verify my antecedents and that of the “person" I had brought in. They had to record my identity and that of whom I had got in. Over and out it was.

It took me a while to let it sink in that a system had indeed taken over. There was nothing else I could do. While I am not a medical professional, I do know that what I could see being executed, was as mandated by the latest advances in medicine. There is nothing else any of the doctors at KEM or somebody at the fanciest hospital could do better. 

At best, the private ones may have offered an illusion of offering better care because it can offer creature comforts like air-conditioned environments, private rooms, higher quality food, reassuring conversations, and a seemingly sanitised environment. It comes at a huge premium though—unaffordable to most uninsured Indians. 

Having witnessed all this, calls were placed to friends of all kinds: those who practice medicine, former teachers from my stream during college and affiliated to KEM Hospital, and friends in the media who report on the domain. A clear consensus emerged: They trust the medical professionals at KEM Hospital more than they do from any private medical entity in the city. 

For that matter, they argue, they trust large medical entities in the country trained to serve the poor, and look chaotic to the untrained eye, more than many professionally run, private medical institutions. This runs contrary to how hospitals such as KEM are perceived by those who live on the top of the economic pyramid. 

But if I were to be in there, I’d sure as hell would be desperate to get out. Why may anyone want to get into a system that seems strained at the leash? Even as this dispatch is being written, 4,500 para medical staffers and nurses have declared they will not report to work because the software that processes their salaries have malfunctioned. They haven’t been paid. How can anyone trust such a system with their lives and the lives of those that matter to them? What was I missing? 

It took me a long while to figure I am missing the forest for the trees. The reason people in the know suggested I place my trust in the ecosystem around KEM Hospital is because experience has taught them it is a trustworthy system. Trust is something that can be measured by metrics like opinion polls. But opinions are, well, opinions. It is subjective. Trustworthiness cannot be measured in any form. This was first put into perspective for me after listening in to the British philosopher Onora O’Neill in a short, but outstanding talk on what we don’t understand about trust. 

‘The aim is to have more trust. Well frankly, I think that’s a stupid aim. It’s not what I would aim at. I would aim to have more trust in the trustworthy…"

“It’s judging how trustworthy people are in particular respects…."

“And I think that judgment requires us to look at three things. Are they competent? Are they honest? Are they reliable? And if we find that a person is competent in the relevant matters, and reliable and honest, we’ll have a pretty good reason to trust them, because they’ll be trustworthy…."

“But that’s what we’re looking for: trustworthiness before trust. Trust is the response. Trustworthiness is what we have to judge. And, of course, it’s difficult. Across the last few decades, we’ve tried to construct systems of accountability for all sorts of institutions and professionals and officials and so on that will make it easier for us to judge their trustworthiness. A lot of these systems have the converse effect. They don’t work as they’re supposed to. I remember I was talking with a midwife who said, Well, you see, the problem is it takes longer to do the paperwork than to deliver the baby.’ And all over our public life, our institutional life, we find that problem, that the system of accountability that is meant to secure trustworthiness and evidence of trustworthiness is actually doing the opposite. It is distracting people who have to do difficult tasks, like midwives, from doing them by requiring them to tick the boxes, as we say." 

“The aim, I think, is more trustworthiness, and that is going to be different if we are trying to be trustworthy and communicate our trustworthiness to other people, and if we are trying to judge whether other people or office-holders or politicians are trustworthy. It’s not easy. It is judgment, and simple reaction, attitudes, don’t do adequately here."

When thought about, Onana O’Neill philosopher sounds so very right. My head was unwilling to trust the doctors at KEM because the attendant paraphernalia that accompanies a privately-run institution does not accompany them. They are burdened by having to attend to people in huge numbers and have no time for nice-talk. There are other pressing things to be attended to. Like fix a few more broken people. What my head couldn’t see is or measure is that they are trustworthy. They work in a demanding environment that insists they take complex calls. When they work as furiously as they do, it is inevitable then that they become better than others in the field. 

But the report cards can only measure what has been gleaned from the text-books. Like facts that can be trusted upon. There is nothing though that can showcase whether these facts will be deployed in just the right way, at the right time, and ingeniously if need be, to create a trustworthy doctor—except the word of those who may have seen them at work. Because trustworthiness, much like respect, must be earned, every day. 

Even as this making itself evident, his relatives started to come in. They looked distraught and looked at me for answers on what is to be done next. I had other things to do. Like meet a few deadlines. 

Calls were placed to two friends. “What do I do now? This guy looks in a real bad shape and his folks don’t know what to do."

I knew what their answer would be. It is what I would have told them if they were where I was. But I needed to be doubly sure. 

“You’ve done what you can. The system has taken over. There is nothing else you can do. Get out and go back to work."

As anticipated, some relatives called up a little later to suggest KEM Hospital is an awful place to be in and that they would much rather he be at private hospital. 

“Bad idea", I said and hung up.

Charles Assisi is co-founder at Founding Fuel Publishing. His Twitter handle is @c_assisi.

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