Inverse care and the role of the state: the health of the urban poor.

Abstract

Tudor Hart's inverse care law, set out in an article in The Lancet in 1971, states that the availability of good medical care tends to vary inversely with the need of the population served. (1) Referring to the national health service (NHS) of the United Kingdom of Great Britain and Northern Ireland, the author argued that the state must play a role in ensuring the health and well-being of those excluded by a range of larger social and market forces. Despite concerns that its services are being eroded, the NHS still adheres to the principle of state provision of publicly funded health care for all. Worldwide, our cities and towns are a growing example of the inverse care law. The inequalities in health-seeking and health outcomes among city subpopulations are well documented. (2) In our decade-long experience working in urban health care in India we found that all too often the state has played a role in furthering the exclusion of the urban poor, with deleterious impacts on their health and health-seeking. Here, we describe this tendency, its impact and what can be done about it. In many parts of the world, cities open up opportunities for making a living, however basic, for people from rural areas. Cities can also offer an escape from the constraints of patriarchy-, gender-, caste- and race-based hierarchies, and this can have positive ramifications for health. (3) However, in many low- and middle-income countries, the transition from a rural to urban existence is part of a larger process of neoliberal economic reform. (4) The result is that the state neglects rural development, thus driving migration to urban areas, but also underfunds urban social welfare, creating pockets of deprivation alongside concentrations of private wealth in towns and cities. (2,3,5) What aggravates the predicament of poor migrants to cities is that they are often regarded as illegitimate non-citizens by the state, even though their contributions to building and running our cities are indispensable. (4) In countries like China and Viet Nam, systems of household registration used to present legal barriers to the entry of many poor persons into cities. By contrast, in India the constitution of the country guarantees the right of any citizen to move to, live and work in any part of the country. Yet various policies suggest a hostile attitude of state authorities towards migrants. (6) Across many low- and middle-income countries, the state does not fulfil a positive duty towards rural-to-urban migrants, such as extending health care, education or social security services to them; rather it acts in a negative way by removing rights, banning livelihoods and demolishing homes. A state that is actively hostile to its most vulnerable urban residents uses many strategies to perpetuate exclusion. One of these is simply making certain urban populations invisible. Across cities in Africa, Asia and Latin America, street children and homeless adults have for generations lived precarious, sometimes violent, and unprotected lives. In a literal sense, they are the most visible of all urban populations, as they have no walls or roof to hide their every move from observers. Yet people of privilege as well as the state treat them as though they do not exist, ignoring any obligations to pursue positive policies for their housing, protection, food and nutrition, health care and education. (4) Instead, these groups must resort to precarious and exploitative relationships with private intermediaries for shelter, employment and other basic needs. (6) Other groups who may be made invisible include people living with stigmatized and debilitating ailments, such as leprosy, mental illness, tuberculosis and acquired immunodeficiency syndrome; old people without care; people living in hunger; and children and women facing abuse inside the home. The anonymity of urban life facilitates the invisibility of vulnerable people, which then absolves the state of obligations towards them. …