Opinion
Trust in times of covid: Health personnel need more of it
Summary
The generation of greater trust in healthcare services will go a long way towards better outcomes
Globally, covid has resulted in massive deaths, unimaginable misery, and immense economic hardships. The pandemic has also sparked unexpected violent outbursts against doctors, nurses and other health personnel across the world. As a 2020 article in The Lancet observed, “Nurses and doctors have been pelted with eggs and physically assaulted in Mexico. In the Philippines, a nurse was reportedly attacked by men who poured bleach on his face, damaging his vision. Across India, reports describe healthcare workers being beaten, stoned, spat on, threatened, and evicted from their homes." These are but a few examples of the horrific violence healthcare personnel have experienced during the pandemic.
Governmental failures to adequately provide and manage resources in this pandemic have meant healthcare workers risking their lives daily by caring for covid patients without adequate personal protective equipment and other safety measures. Thousands of these workers have contracted the virus and been seen as public health hazards themselves. They have thus been targeted while performing their professional duties.
Trust is fuzzy and thus difficult to define. But it has many attractive features that promote efficiency, cooperation and well-being. Trust in medical services can be seen as trust in doctors and medical institutions, and involves two questions: “Whether the doctor and medical institutions are competent to make a diagnosis and provide treatment" and “whether the doctor and medical institution will act in the best interest of the patient". But, broadly, the salience of trust depends greatly on the patients’ circumstances, the extent of risk, characteristics of their illnesses and needs, and their access to information.
Unsatisfactory performance usually results in forgiveness. Besides, trust has a ‘cliff effect’ in which trust builds for some time but then extends beyond a doctor’s actual trustworthiness, leading to an inevitable steep decline or sense of betrayal (say, if a patient dies). More worrying is the likelihood of a violent turn taken by the deceased’s relatives or friends.
Although multiple reforms have been proposed, including draconian punishment, in our view, trust holds the key to these reforms. To rebuild it, we must understand the co-variates of trust in public and private hospitals. Hence we analysed trust in public and private healthcare providers, based on two rounds of the India Human Development Survey, covering 2005 and 2012. Although not-so-recent, it is the only all-India panel survey with a question on trust in health systems. To assess the quality of medical treatment received, respondents were asked to rank hospitals/doctors in terms of their level of confidence: hardly any confidence, only some confidence, and a great deal of confidence.
As much of the violence during the pandemic was directed at public healthcare providers, we confine our remarks to factors associated with trust in them.
Comparison across asset quartiles shows that the most affluent (in the fourth quartile) had the lowest share with high confidence in 2012, and the least affluent, a higher share of it in the public provision of healthcare. An important marker of socio-economic status is caste. A comparison for 2012 shows that Schedule Castes had the highest share with high confidence in public healthcare, and Other Backward Classes the lowest. Education-wise, graduates had the lowest share with high confidence in public medical services (just above 50%), while those with primary education or less had the highest. Strikingly, those with moderate prevalence of non-communicable diseases (NCDs) had a higher share with high confidence in public healthcare than those without NCDs. The prevalence of disabilities presents a contrast. The lowest share with high confidence is found among households with a high burden of disabilities. Urban households were more likely to show high confidence in 2012, relative to rural households. In sum, India’s lower socio-economic strata showed a great deal of confidence, while the affluent, better-educated and those better networked had low confidence, as they were presumably better informed. So a drastic overhaul of public healthcare would reinforce the trust of the lower strata and help build trust among the latter.
Although we are unable to link trust in healthcare with pandemic-time outbursts of violence against health personnel, insightful case studies show that mistrust sparks such violence, frequently triggered by death. The focus must shift from preventing violence against doctors to restoring doctor-patient trust. Indeed, cracking down on violence and enhancing security measures are unlikely to fundamentally alter doctor-patient mistrust.
While the Protection of Medicare Service Persons and Medicare Service Institutions (Prevention of Violence and Damage to Property) Act has been adopted by about 23 Indian states, it has not been properly implemented. The Act does not feature in the Indian Penal Code (IPC), which makes it difficult for victims to approach the police for help. Often, they are not even aware of this law.
While health personnel must treat patients with dignity, patience and due care, it is also important that inequities within the health system in terms of the heavy workload of nurses and doctors, protection lacunae and a lack of essential supplies (such as beds, vaccines, oxygen cylinders and ultrasound machines) are effectively remedied.
In conclusion, although building patient-doctor/hospital trust is a daunting task, the challenges are not insurmountable and it would offer the country multiple benefits.
Vani S. Kulkarni & Raghav Gaiha are, respectively, associated with the department of sociology, University of Pennsylvania; and research affiliate, Population Aging Research Centre, University of Pennsylvania.
