Views & Reviews From the frontline

The inverse care law has had its day

BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39146.637685.59 (Published 08 March 2007) Cite this as: BMJ 2007;334:538
  1. Des Spence (destwo{at}yahoo.co.uk)

    Half way through my sixth year at school I received an unconditional acceptance from university. My last few months were spent playing cards, dodging class, sharing cigarettes in the toilets, and attempting to blow up the chemistry equipment. A better preparation for university I could not have had. It was preferable to the current fad of sending our children on a gap year to naively smoke cannabis on a beach in countries that impose a life sentence for listening to Janis Joplin.

    I did learn one thing in those last six months: the inverse square law. This relates to decay in the intensity of electromagnetic waves, so that at twice the distance one receives a quarter the dose. At a certain point, therefore, changes in the power have little impact on the dose of light received. This seemingly irrelevant law of physics actually applies to medicine: beyond a certain point, more resources have a negligible impact on health. Think UK versus USA.

    We have another irrefutable medical law: the inverse care law. “The availability of good medical care tends to vary inversely with the need for the population served”—that is, affluent people get better health care than poor people despite being in less need of it. It was Julian Tudor Hart who coined this idea, and a generation of public health consultants have enjoyed surfing the waves caused by his landmark observation. But is it time to question one of the foundations of modern medicine?

    The Western world has changed. Absolute poverty has long gone and been replaced by relative poverty. The most deprived people still have the shortest life span, but the solution to this has nothing to do with medical care and much to do with social issues. The impotence of modern medicine to deliver absolute health improvement is not all that is at issue, though. The reality is that the inverse care has been turned upside down, with affluent people having worse relative health.

    The affluent politely queue for screening that they will never benefit from in a score of lifetimes but are guaranteed overdiagnosis and needless interventions. The sheepdogs of fear and profit herd them into the pens of “pre” diseases (non-disease), restricting their lifestyle unnecessarily, so they are shorn of any enjoyment in life. Cold and bleating, they still gulp down the fix of poly-medication, again oblivious to the infinitesimal benefit to their health. In the grey drizzle of this existence they fail to see that all this intervention is a leap of faith with scarce long term data, especially in low risk herds. The less affluent graze on the hills above the pens, exposed to the elements but warm and above all else free.

    Iatrogenic morbidity poses the greatest threat to health in the West. The inverse care law has run its course. Young public health wannabes might consider arguing that we should cap health spending, for the sake of the ailing affluent.

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