Julian Tudor Hart
Published: 28 July 2018
Article Info
Radical general practitioner. He was born in London, UK, on March 9, 1927, and died from complications of a bowel perforation in Swansea, UK, on July 1, 2018, aged 91 years.
A visionary general practitioner (GP) who spent his career practising what he preached, Julian Tudor Hart is best known as the author of the inverse care law: “The availability of good medical care tends to vary inversely with the need for it in the population served.” Like Karl Marx, his guiding inspiration, Tudor Hart believed that it was not enough to interpret the world in various ways; the point was to change it. That his law was intended as more than a neutral observation becomes clear when you read the less quoted sentences that follow it in his celebrated 1971 Lancet paper. The law, he wrote, “operates more completely where medical care is most exposed to market forces, and less so where such exposure in reduced. The market distribution of medical care is a primitive and historically outdated social form.”
Tudor Hart's urge to change the world found expression in his professional life. “He was the first GP to measure the blood pressure of all his patients”, says Professor Graham Watt, Honorary Senior Research Fellow in Glasgow University's Institute of Health & Wellbeing. “At the time, hypertension was often thought of as a condition that had to be managed by hospital specialists”, adds Sir Andy Haines, Professor of Environmental Change and Public Health at the London School of Hygiene & Tropical Medicine. “Julian was a major force in ensuring that it became embedded in primary care.” His endeavours paid off. “When in 1990 he published the results of 25 years of what he'd been doing compared to a neighbouring practice”, says Watt, “he showed that mortality was down by about 30%”. This, Watt believes, was attributable to a number of interventions besides blood pressure measurements. “The main thing, I think, was that he was providing unconditional personalised continuity of care for all his patients”, says Watt. Tudor Hart was above all a committed family doctor.
Tudor Hart studied medicine at St George's Hospital Medical School in London, UK, qualifying in 1952 and spending 5 years as a GP in an impoverished area of west London. “[The epidemiologist] Richard Doll, who was a patient of Julian's…suggested that his personality, which was described as being somewhat obsessional, might be suited to research”, explains Watt. Tudor Hart left general practice to study epidemiology with Doll, then joined Archie Cochrane to work on pneumoconiosis at the Medical Research Council (MRC) Epidemiology Unit in Llandough, Wales. In 1961, dissatisfied with diagnosing illness but not treating it, Tudor Hart joined a general practice in the south Wales coal mining village of Glyncorrwg. With the support of the MRC, and the indispensable help of his wife Mary, a researcher, he transformed it into a research practice. “By going to the back of beyond he was able to develop in microcosm a lot of ideas, and had the freedom to do it”, says Watt who, like Haines, spent a period as one of Tudor Hart's research fellows. The understanding in the practice was that in return for a level of medical care unlikely to be matched elsewhere, the patients would constitute a group of research participants. As Watt comments, although it was mutually beneficial, a modern research ethics committee might criticise this relationship.
Haines describes Tudor Hart as one of the great thinkers about health care and an inspiration, even to those who didn't share his politics: “He spoke to a wider group of people…because he was able to talk so cogently about the importance of social justice. He was a powerful advocate of a more equitable health system.” Tudor Hart was often outspoken. “He was not afraid of tackling powerful interests”, Haines adds. He was critical of many in his profession—and of himself. “He's the only person I know who's published a series of 500 case reports of deaths in his own practice.”
Tudor Hart was embedded in his community. According to Watt, “Glyncorrwg was the kind of community Julian wanted to belong to, and the only way he could imagine belonging to it was as a doctor”. In this his career resembled that of his father Alexander, also a lifelong socialist and a GP in a Welsh colliery village. His mother Alison Macbeth was also a doctor. Besides his wife Mary, Tudor Hart leaves their children Robin, Rachel, and Ben, also a GP, as well as Penny and Alison, daughters from his first marriage to Joyce. “Julian believed in science”, says Watt. “He had incredible mental energy and he wasn't just producing evidence, but using it to inform his practice.”
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Slide de uma aula inaugural do Curso de PG Epidemiologia que dei em 2007
Dr.
Julian Tudo Hart, General Practitioner de Gales, hoje aposentado (agora falecido), autor
do primeiro estudo epidemiológico sobre pressão arterial numa comunidade
inteira, a população que tinha sob sua guarda, e não somente HA mas diversas
outras variáveis que ele anotava com muito cuidado em seu dia a dia. Ele também
é responsável pela lei inversa da assistência ao observar que aqueles que mais
necessitam, recebem pior qualidade de assistência.
Conversando
com ele em Bogotá, no início dos anos 80 ele me falou de uma hipótese que já vi
formulada posteriormente: “a hipertensão é uma resposta daqueles que têm
equipamento para tanto, à uma depressão larvada”. Isto coincide com a
constatação de uma depressão generalizada no mundo dito civilizado, coincidente
com a transição demográfica – urbana – industrial – capitalista - consumista.
Uma
das bases para esta teoria está nos mediadores químicos envolvidos na sua fisiopatogenia que são os mesmos envolvidos com
estresse, com cocaína e outras drogas, com tabagismo, e com violência.
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"Although the #NHS helped to counteract the inverse care law, it did not abolish it." @MichaelMarmot on the continued relevance of the inverse care law https://www.bmj.com/content/362/bmj.k3216 …
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