The McKeown Thesis and Public Health:

Time for a Dignified Burial?

Dr Gracia Fellmeth

Specialty Registrar Public Health

Oxford Deanery

Overview• The Question

– Does McKeown still matter, or is it time for a “dignified burial”?

• Methods – Historical literature review

• Findings– McKeown and his thesis– Context– Criticism and Support– Relevance today

• Conclusions

Thomas McKeown (1912-1988)

Source: BMJ 1988; 297: 129

McKeown’s Question

Source: United Nation World Population Prospects

McKeown’s Methods

• Annual Reports of Registrar General (1838 onwards)

• Identified 4 main causes of death:– Airborne infections– Water- and foodborne infections– Contagious infections– Degenerative & congenital diseases

McKeown’s MethodsOffered possible explanations for mortality

decline:

i) Spontaneous change in virulence

ii) Reduced exposure to infectiona) Increased levels & quality of vaccination

b) Improved sanitation

iii) Improved host defence following exposurea) Improved medical treatments

b) Improved nutritional status

Mortality Rates in England & WalesTuberculosis Mortality Scarlet Fever Mortality

Smallpox Mortality Diphtheria Mortality

Redrawn from McKeown (1976) by Gherardi (nfs.unipv.it/nfs/minf/dispense/immunology/immun.html).

McKeown’s MethodsOffered possible explanations for mortality

decline:

i) Spontaneous change in virulence

ii) Reduced exposure to infectiona) Increased levels & quality of vaccination

b) Improved sanitation

iii) Improved host defence following exposurea) Improved medical treatments

b) Improved nutritional status

McKeown’s Conclusions

• Population growth and improved health between 1770-1900 due to environmental and nutritional factors

• Impact of medicine “negligible”

• Medical care system received more credit & financial support than justified given its effectiveness

Context

• 1950s - 1960s: Golden Age of Medicine

– Optimism in the power of medicine

– Rapid developments in science and technology

– Unlimited spending on unlimited medical care

Criticism

• Primary data– Numerator vs denominator; incompleteness;

misclassification…

• Methodology– Vague terminology; infection vs mortality;

“Holmesian” approach…

• Interpretation– Background trends; conclusions drawn…

So is it time to “bury” McKeown?

McKeown’s Relevance

• Technical Relevance– Aspects of his theory remain correct

• Conceptual Relevance– His approach & way of thinking remain

important

Technical Relevance

• Nutritional status important

• Limitations of clinical medicine– Prevention vs Cure

• Non-medical influences on health – “Social Determinants” now considered

fundamental to public health

• Resources remain skewed

UNICEF (1990) Global conceptual framework of the causes of child malnutrition

Technical Relevance

• Nutritional status important

• Limitations of clinical medicine– Prevention vs Cure

• Non-medical influences on health – “Social Determinants” now considered

fundamental to public health

• Resources remain skewed

Technical Relevance

• Nutritional status important

• Limitations of clinical medicine– Prevention vs Cure

• Non-medical influences on health – “Social Determinants” now considered

fundamental to public health

• Resources remain skewed

Barton and Grant (2006) adaptation of Dahlgren and Whitehead (1991)

Technical Relevance

• Nutritional status important

• Limitations of clinical medicine– Prevention vs Cure

• Non-medical influences on health – “Social Determinants” now considered

fundamental to public health

• Resources remain skewed

“The first difficulty is to see

that there is a difficulty.”

Bertrand Russell

Conceptual Relevance

• Questioned status quo by asking a “radical question” (Bynum 2008)

• Challenged supremacy of scientific medicine (Farrow 1987)

• Overturned “prevailing orthodoxy” in historical interpretation (Grundy 2005)

• Reminds us of need to be ever-critical

Direct Influence

• Lalonde Report 1974

• Importance of biology, lifestyle, environment, & health services

• Healthy Cities 1985– Improving health of disadvantaged– Shift resources towards primary care

Adapted from Lalonde’s Health Field Concepts, 1974

Indirect Influence

• WHO Alma Ata Declaration 1978

• Black Report 1980

• Ottawa Charter 1986

• Acheson Report 1998

Current Affairs

• 2008 World Health Assembly – renewed interest in social determinants of health

• US Health Reform: focus on prevention

Conclusion• McKeown Thesis controversial and flawed…• But continued technical & conceptual relevance• McKeown raised fundamental issues:

– What are the most important determinants of health?– How should resources be distributed?

• These questions remain largely unanswered… • Revival of McKeown’s ideas required to continue

improving population health

Thank you