The Enduring Power of the #InverseCareLaw

Q: Ever read a paper that resonates for days / months / years afterwards?

Mine is from @TheLancet 1971. I would love it to become obsolete, but its relevance endures, including in relation to #COVID19

https://bit.ly/2Bejii0 

1/18
The author - Julian Tudor Hart - died 2 years ago today.

I read the paper before I knew anything about Hart, but he led an amazing life – in General Practice in S Wales, community-based research (& his family has an intriguing back story). https://www.theguardian.com/society/2018/jul/12/julian-tudor-hart-obituary

2/18
The #InverseCareLaw paper runs through creation & early decades of the #NHS & makes 2 points about equity- the #InverseCareLaw.

The 1st line (red) is often cited without reference to 2nd (green) on market forces (which annoyed Hart).

(Hart’s politics are pretty clear!)
3/18
He later added:

"To the extent that health care becomes a commodity it becomes distributed just like champagne. That is rich people get lots of it. Poor people don’t get any of it."

[substitute 'champagne' for any scarce commodity including #COVID19 related]

4/18
The #InverseCareLaw has been explored and elaborated many times since, with more evidence pinned to the theory. This is from 2001:
https://www.kingsfund.org.uk/publications/articles/inverse-care-law
5/18
The #InverseCareLaw had a profound effect on me as a student – I had thought about poverty and inequality before, but never with any real structure.

It inspired my PhD; & my ‘half-life’ career in #globaldev as a social development and poverty-focused governance person.
6/18
The #InverseCareLaw also reminded me of watching the TV adaptation of the ‘The Citadel’ - like Hart, Cronin was a medical doctor with a practice serving the coal mining communities of South Wales.
https://en.wikipedia.org/wiki/The_Citadel_(novel)
7/18
Fast forward to 2020:

I still chew over the #InverseCareLaw when I think about challenges in service delivery, inclusion, equity, & state legitimacy – in #globadev or in UK life.

[😏Though I am open minded about public and private sector delivery models…]
8/18
e.g. I think about the #InverseCareLaw in relation to @GAGE_programme’s work on understanding & including the needs of adolescents in #COVID19 responses in Ethiopia,
https://twitter.com/GAGE_programme/status/1277859413227798529
9/18
...and I think about the #InverseCareLaw in relation to @ACE_SOAS & @LSHTM work on political corruption & the nature of health staff absenteeism - e.g. the strong pull of urban & pvt practice, at expense of rural need (echoes of Hart & Cronin) https://twitter.com/ACE_soas/status/1167112926689280000
10/18
I think #InverseCareLaw when I read Impact Evaluations (RCTs – education, health, violence) that report a positive impact:

Q: who didn’t benefit – is it structural? Are those most in need not benefiting?

(in some papers it’s not clearly reported)
@Fihi_maFihi
11/18
The #InverseCareLaw never sleeps - it is nearly always being referred to by someone, somewhere – just check Twitter. https://twitter.com/search?q=%22Inverse%20care%20law%22&src=typed_query&f=live
12/18
Here @devaki_nambiar & @harsh_mander use the #InverseCareLaw to frame urban health, underlining role of the state in meeting the needs of the urban poor (needs no doubt multiplied under #Covid #lockdown
https://www.who.int/bulletin/volumes/95/2/16-179325/en/
13/18
Inverse care and the role of the state: the health of the urban poor

article published in February 2017

https://www.who.int/bulletin/volumes/95/2/16-179325/en/
#InverseCareLaw and #COVID19 ?

It's used here by Mahendra Patel to frame analysis about #COVID19 and the particular vulnerability of BAME communities
https://www.pharmaceutical-journal.com/news-and-analysis/opinion/we-must-tear-down-the-barriers-to-equality-for-bame-communities-highlighted-by-covid-19/20208060.article?firstPass=false
14/18
We must tear down the barriers to equality for BAME communities highlighted by COVID-19

There are two ways that we can begin to address the long-running health disparities between different ethnic groups, which have been highlighted by the disproportionate effects of the COVID-19...

https://www.pharmaceutical-journal.com/news-and-analysis/opinion/we-must-tear-down-the-barriers-to-equality-for-bame-communities-highlighted-by-covid-19/20208060.article?firstPass=false
... and the #InverseCareLaw will be on my mind when we think through the challenges of achieving high coverage rates in FCAS, when a #COVID19 Vaccine becomes available (fingers crossed)
https://twitter.com/PeterEvans_Guv/status/1273888251695292416
15/18
#InverseCareLaw - get the picture?

A 1971 paper that kick-started thinking about global health inequalities and continues to influence global public policy today.

Thank you Julian Tudor Hart!

https://twitter.com/trishgreenhalgh/status/1013354111968915457
16/18
Postscript:

In 2019 my daughter cited Tudor Hart in her 1st year undergrad essay about socio-economic determinants of health & care seeking in Scotland (& not only because her old man keeps banging on about the #InverseCareLaw).
17/18
And finally -

MISSED PUN-DAMENTALS

It took me nearly 50 years to realise that Hart's 'Inverse Care Law' is a pun on the 'Inverse Square Law' in Physics

( @zaza_curran - I feel cheated)
18/18
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