Elsevier

The Lancet

Volume 360, Issue 9328, 20 July 2002, Pages 252-254
The Lancet

Essay
The inverse care law today

https://doi.org/10.1016/S0140-6736(02)09466-7Get rights and content

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Medicine works

In an influential book,3 also published in the 1970s, Professor Tom McKeown claimed that health services had contributed little to improvements in public health. Looking back over 100 years, this observation was largely true at the time. The first randomised controlled trial took place at the same time that the NHS was set up. Looking back over the past 50 years, however, McKeown's statement is no longer true. There is now a substantial armamentarium of interventions of proven effectiveness in

The problem of non-response

In studies that involve the general population, epidemiologists believe they have done well if they achieve response rates of 80%. In studies done in areas affected by severe socioeconomic deprivation, a response rate of 60% is judged respectable. Epidemiologists tend to try not to recruit the remainder of the population because they recognise that the work involved in recruiting the last 20% could be as great as that involved in recruiting the first 80%. Primary healthcare teams have no such

Comorbidity

Barbara Starfield argued that there is “no good evidence base for diagnosis and intervention in primary care, where the nature of the problems and the extent of comorbidity make irrelevant the application of most clinical guidelines.”6 She was writing generally, and not from a UK perspective, but what she said is particularly true of the type of comorbidity that is seen in deprived areas.

The comorbidity of socioeconomic deprivation needs to be distinguished from the multiple pathology that is

Confounding the inverse care law

Julian Tudor Hart practised what he preached, combining the skills of epidemiology and clinical medicine within a single population. In 1991, he reported the results of 25 years of case finding and audit in a socially deprived community.8, 9 Compared with a neighbouring village, which had similar amounts of severe socioeconomic deprivation but a more traditional approach to medical care, premature mortality was 28% lower in his village at the end of the period.

Although not a rigorous scientific

Obstacles

Whatever the lessons to be learned from this example, major obstacles stand in the way of policies to counter the effects of the inverse care law.

First, there is inadequate recognition of the contributions that clinical services make to public health, and the extent to which correction of variations in service delivery might contribute to public-health gain. Neither the Scottish nor the English policies to address inequalities in health recognise the inverse care law as contributing

Conclusion

Hart's original paper, introducing the inverse care law, was not a systematic review of evidence but a polemic describing the effect of market forces on health care. Then, as now, there was less evidence than one might expect. Although commercial solutions to health-care problems are still a threat to public-health equity, this is no longer the most important formulation of the inverse care law in the UK. As affluent groups accrue the public-health benefits of effective clinical interventions,

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