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 Methods
Offered possible explanations for mortality
decline:
i) Spontaneous change in virulence
ii) Reduced exposure to infection
a) Increased levels & quality of vaccination
b) Improved sanitation
iii) Improved host defence following exposure
a) Improved medical treatments
b) Improved nutritional status
Mortality Rates in England & Wales
Tuberculosis Mortality
Smallpox Mortality
Scarlet Fever Mortality
Diphtheria Mortality
Redrawn from McKeown (1976) by Gherardi (nfs.unipv.it/nfs/minf/dispense/immunology/immun.html).
McKeown’s Methods
Offered possible explanations for mortality
decline:
i) Spontaneous change in virulence
ii) Reduced exposure to infection
a) Increased levels & quality of vaccination
b) Improved sanitation
iii) Improved host defence following exposure
a) 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
Adapted from Lalonde’s Health Field Concepts, 1974
• Healthy Cities 1985
– Improving health of disadvantaged
– Shift resources towards primary care
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