In This Issue: Equity—Global Theme Issue on Poverty and Human Development

EQUITY

An editorial by Hagopian⁷ considers a study in this issue by Starfield and Fryer⁸ in terms of how to “balance the rights of individuals to move about the globe in pursuit of their own happiness with the needs of the communities that have equipped them for their mobility.” The study in question comes to the scandalous conclusion that the United States is stealing graduates of medical schools in the world’s most deprived nations to compensate for our own inability to design a health care system that attracts graduates into primary care.

Reductions in the US primary care workforce will differentially affect disadvantaged populations, particularly children, according to Ferrer’s careful analysis of nationally representative data.⁹ In documenting that family physicians are the only clinician group which does not show disparities in access across patient income levels, he shows that reductions in the family physician and primary care workforce are likely to increase inequalities in health care and health.

The inverse care law was first articulated by Julian Tudor Hart to describe the phenomenon that those who need medical care the most are least likely to get it.¹⁰ Now Mercer and colleagues identify mechanisms by which this law operates, studying a sample of physicians and patients in deprived and affluent areas of western Scotland.¹¹

Focusing on low-income families, DeVoe and colleagues analyze the patient voice to identify a typology of barriers that parents face in obtaining health care for themselves and their children.¹²

The complex causality in obesity and diabetes in vulnerable populations are difficult to handle because of multilevel interrelationships. Candib’s elucidation helps us to understand and ultimately to act on the many lever points.¹³

Together, these studies show a consistent pattern of societies ignoring the needs of the disadvantaged. This is easy to do, particularly when we segregate our living and work places by economic status. This segregation of place promotes narrow vision and a stunted sense of commonality.

Physicians tend to feel good about what we do with the people who come through our doors. We may try to optimize our care of individuals by applying evidence-based guidelines based on studies of even more selected people. We rarely consider the greater good that could be accomplished by using a bit less of the many marginal and expensive technologies we wield and providing basic services to those who have limited access to care.

Policy makers point to programs designed to increase access to medical care. We do not consider the possibility that the health of the population could be enhanced more by spending less on health care and more on education, particularly targeted toward those whose educational opportunities are substandard.¹⁴

Macaulay lights a path through this darkness by showing how participatory research can be a method for developing evidence that is relevant to the care of often underserved communities.¹⁵ She provides a mechanism for integrating evidence-based practice and policy with efforts to increase equity—not through advocacy from the outside but through partnership that promotes inclusion.

WELCOMING A NEW EDITOR

We are delighted to welcome John J. Frey III, MD, as a new associate editor at the Annals. Dr Frey joins us at a time when the number of manuscripts received is increasing and when the diversity of topics that make up the field of primary care and health care require broadening our expertise.

Dr Frey is a family physician, educator, and leader. He has experience in medical editing for Family Medicine and the Wisconsin Medical Journal. He recently completed his second term as a member of the National Library of Medicine Literature Selection Technical Review Committee. Dr Frey brings to his role as editor an international perspective, a strong grounding in the fundamentals of generalist practice, and a sanguine vision of the future.

Please share your insights by joining the Annals online discussion at http://www.AnnFamMed.org.