U.S. Health Care Faces A Crisis of Trust | Opinion

The COVID vaccines are working. Studies paint a clear picture, the FDA has now given full approval to the Pfizer version and public health experts are unanimous: you and yours should almost certainly get vaccinated. But expertise is of limited utility without public trust, and American society is in the throes of a terrible and growing crisis of trust.

COVID vaccine hesitancy, so inexplicable and frustrating when viewed in isolation, is just one manifestation of this crisis, in which conspiracy theorists and anti-vaxxers are merely opportunistic bit players. The larger story is one of smooth-talking, utility-maximizing, efficiency-chasing technocrats who have built quiet but remunerative careers draining the humanity out of the healing arts. Under their leadership, medical systems have metastasized, profits have spiked and patients have been left feeling alienated and unseen.

In 1966, more than three-quarters of Americans reported having high confidence in our medical leaders. By 2018, that number had fallen to 34 percent. This decline accompanied a massive rise in specialized know-how, technical sophistication, pharmaceutical wizardry and efficiency-boosting consolidation. Medicine has never been more profitable, and a contemporary physician has a far more effective set of tools to wield than did her counterpart in 1966. The medical industry appears to be thriving. The problem is that many of these ostensible improvements have shifted the center of gravity from practitioner-patient encounters to system-patient encounters. That shift has been very bad for the building and preservation of trust.

As early as 1982, the sociologist Paul Starr was warning that power was migrating from the skilled hands of physicians into "complexes of medical schools and hospitals, financing and regulatory agencies, health insurance companies, prepaid health plans, and health care chains, conglomerates, holding companies, and other corporations."

These processes have only accelerated in the past 40 years. Specializations have become ever more siloed and advanced. Reliance on increasingly dazzling (and dazzlingly expensive) machines has made the large, wealthy, urban, heavily administrated hospital the default model. Private equity has bought up and consolidated small hospitals, and rural hospitals have begun to go extinct. Administrators have put pressure on caregivers to goose the bottom line by packing their schedule with brief, perfunctory visits, which make genuine doctor-patient engagement all but impossible.

Profitable as these changes have been, they've had a devastating effect on the community of medical practitioners. You don't have to spend much time among doctors or nurses before you hear a common complaint: we hardly work for patients anymore. We work for massive machines, and bean-counting administrators who impose "best practices" from invisible heights. These new masters win compliance through the power of the purse, but they have not inspired trust among their subordinates; a recent study by the University of Chicago's National Opinion Research Center (NORC) found that only half of physicians say that they trust health care leaders and executives.

COVID vaccine
SAN RAFAEL, CALIFORNIA - OCTOBER 01: A Safeway pharmacist administers a Pfizer COVID-19 booster vaccination at a vaccination booster shot clinic on October 01, 2021 in San Rafael, California. Justin Sullivan/Getty Images

This is a bad way to do medicine. Humans, by our nature, build trust eyeball to eyeball, over time. If your family doctor, who's known and cared for you and your family for years, tells you to take a pill, forgo a procedure or get a vaccine, that's one thing. If a harried resident, attending or traveling nurse, who just happens to be on the floor right now, tells you the same, that's a different matter; you scarcely know that person as a person. Indeed, in the same NORC survey cited above, only 65 percent of patients agreed that their doctors know them as people.

On what grounds, then, does a physician in a large, anonymized hospital make recommendations? In the absence of the kind of trust that comes from personal proximity and acquaintance, the doctor or nurse approaches her patient as a walking (though often well-meaning!) credential, a pedigree, a representative of the system or even of the massive edifice of modern science. These things aren't nothing—they are perhaps the most prestigious and revered markers we have in our society today—but in matters of life and death, they are not enough. Even if patients believed the system was perfectly calibrated to facilitate their well-being, an absolutely benevolent system would be no substitute for long personal acquaintance with a wise and compassionate person.

The attempt to replace personal knowledge and trust with standardization, technical virtuosity, centralized bureaucracy and elite credentials is a long-running theme of industrial modernity. As the sociologist James C. Scott argues in his landmark book Seeing Like a State: How Certain Schemes to Improve the Human Condition Have Failed, these mechanisms are often designed primarily to make complex human systems measurable, so as to more efficiently extract service, fealty or money. But the process of making complex systems more legible to value-extracting bureaucrats often tends to stifle the organic, ground-level relations and processes that made the system work in the first place. It's a self-defeating move. Soon enough the system is creating less and less value, sometimes to the point of total collapse.

The American medical system is not yet at the point of total collapse. A recent poll found that COVID vaccine hesitancy is steadily decreasing; the percentage of Americans who say they are unlikely to be vaccinated currently stands at 20 percent, down from 34 percent in March. However, the main driver of this decrease was not a rise in trust, but the rise of mandates. Many Americans now face a choice: either get the vaccine, or become excluded from education and gainful employment.

The move to mandates is probably a wise idea under the circumstances, but the recourse to coercion, in a time and place marked by such impressive medical know how, is a sign of systemic failure. If the medical system in America wants a practice characterized by trust, rather than anarchy or coercion, it needs to turn its attention from the bottom line, to those tender moments when genuine care is administered, and trust is built.

Ian Corbin is a Senior Fellow at the think tank Capita, where Joe Waters serves as CEO.

The views expressed in this article are the writers' own.