The penny finally dropped for me a few years ago when researching a story about how heavily Australia relies on other countries, especially poorer ones, to provide doctors for so many of our rural and remote communities.
I came across a doctor who had left Zimbabwe, a country devastated by HIV, poverty and turmoil, expecting to bring his family to the relative comfort of a wealthy country.
He was surprised when he instead found himself, working at an Aboriginal medical service in central Australia, dealing with problems that were not so different to what he knew from home.
He felt he had been left to flounder in the NT; he was a stranger to this country and its health system, yet was expected to do one of the most difficult jobs in Australian medicine with little support.
For me, this doctor’s story has come to epitomise a principle whose fundamental truth has been borne out by many studies since a GP working in Wales, Dr Julian Tudor Hart, first coined the term, “the inverse-care law”.
In a landmark article in The Lancet in 1971, he wrote:
In areas with most sickness and death, GPs have more work, larger lists, less hospital support, and inherit more clinically ineffective traditions of consultation than in the healthiest areas; and hospital doctors shoulder heavier case-loads with less staff and equipment, more obsolete buildings and suffer recurrent crises in the availability of beds and replacement staff. These trends can be summed up as the inverse-care law: that the availability of good medical care tends to vary inversely with the need of the population served.
In other words, the poorer you are, the more likely you are to suffer health problems and the less likely you are to get the health care you need.
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So many aspects of our health system and broader society combine to ensure the inverse-care law remains as entrenched as ever. You only have to look at this recent report on the health of young Australians showing those from the most disadvantaged areas were almost twice as likely to die between the ages of 12 and 24 as those from better-off areas.
And yet, governments of all persuasions have a long history of implementing health policies which favour the better-off. The massive investment of public money in the private health sector, supported by both major parties, is just one example.
One reason is the power over health policy of professional groups whose members benefit directly from the inverse-care law. Treating the ailments of the wealthy suburbs is so much more pleasant and profitable than doing it tough in Tennant Creek.
So, remember the inverse-care law the next time you hear the AMA wringing its hands over indigenous health. If the “most powerful union in Canberra”, as it is sometimes called, really wanted to make a difference to the health of disadvantaged groups and communities, it would be pushing for changes many of its members wouldn’t like.
Such as a fundamental shift in the status quo, which gives most clout and money to big-city specialists and least to GPs, nurses and other community workers doing the hard yards in poor or otherwise disadvantaged areas.
As if. That’s just about as likely as health ministers making the first critical test of any proposed health policy: will it help undo the inverse-care law? Dream on …
Tomorrow: why doctors enjoy the good life