Vector Issue 12 - 2011

the need for interventions to be proportionate to the
degree of disadvantage, and hence applied in some
degree to all people, rather than applied solely to the
most disadvantaged 5 .
The impact of comparatively modest interventions
can be seen by reviewing some of the strategies
employed so far in reaching the MDGs. For example
the first goal is to ‘halve, between 1990 and 2015, the
proportion of people whose income is less than one
dollar a day’. Imagine the impact of developing a
program that doubles a person’s income to two dollars
a day. Now reflect on the difference an extra dollar
a day would make to you. This prompts another law
to be considered: the law of diminishing returns.
Applied to Australian health the law suggests that
the more we reach health actualisation (apologies to
Maslow and his hierarchy of needs), the more the cost
to achieve a marginal gain in personal health and no
improvement in population health - in fact there is
the potential for a net loss because of the opportunity
cost associated with the provision of boutique health
services as opposed to providing basic health care to
those who need it most.
Another lesson for us is that when global threats
to health become more manifest during this
decisive decade, there is the need to emulate the
multidimensional approach to ensure that the
factors that determine health are enhanced and
strengthened. Many of these factors included in
the MDGs are summarized in a recent extension of
the Dahlgren and Whitehead model to include the
environmental influences on health [6,7 .
The challenges for health systems across the world
are great but, ironically, it is the developed world
where the dominance of tertiary services has led to
an exponential and unsustainable increase in costs.
Thanks to the MDGs we are likely to see enormous
health gains from investing in the determinants of
health and in primary health services and hopefully
the Australian medical leaders of the future will
take note of where they need to focus their efforts
to achieve the greatest impact on the health of
Australians.
1. National health goals and targets: summary of draft reports. Canberra: Department of Human Services and Health;
1994
2. Rose G. The strategy of preventative medicine. Oxford University Press; 1992.
3. Hart JT. The inverse care law. The Lancet 1971 Feb 27; 1(7696):405-12.
4. O’Dea JF, Kilham RJ. The inverse care law is alive and well in general practice (Editorial). Med J Aust 2002; 177:78-
79.
5. Health equity: an election manifesto? (Editorial). The Lancet 2010; 375(9714):525.
6. Dahlgren G, Whitehead M. Tackling inequalities: a review of policy initiatives. Tackling inequalities in health: an
agenda for action. London: King’s Fund Institute; 1995
7. Barton HAGM. A health map for the local human habitat. J R Soc Promot Health 2006; 126(6): 252-261.
developing nations
h Metropolitan Area Health Service, WA.
www.ghn.amsa.org.au
vector FEB 2011
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