The McKeown Thesis and Public Health: Time for a Dignified Burial?

1. The McKeown Thesis and Public Health:Time for a Dignified Burial? Dr Gracia Fellmeth Specialty Registrar Public Health Oxford Deanery

2. 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

3. Thomas McKeown (1912-1988) Source: BMJ 1988; 297: 129

4. McKeown’s Question Source: United Nation World Population Prospects

5. 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

6. 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

7. Mortality Rates in England & Wales Tuberculosis Mortality Scarlet Fever Mortality Smallpox Mortality Diphtheria Mortality Redrawn from McKeown (1976) by Gherardi (nfs.unipv.it/nfs/minf/dispense/immunology/immun.html).

8. 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

9. 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

10. 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

11. Criticism • Primary data • Numerator vs denominator; incompleteness; misclassification… • Methodology • Vague terminology; infection vs mortality; “Holmesian” approach… • Interpretation • Background trends; conclusions drawn…

12. So is it time to “bury” McKeown?

13. McKeown’s Relevance • Technical Relevance • Aspects of his theory remain correct • Conceptual Relevance • His approach & way of thinking remain important

14. 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

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

16. 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

17. 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

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

19. 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

20. “The first difficulty is to see that there is a difficulty.” Bertrand Russell

21. 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

22. 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

23. Indirect Influence • WHO Alma Ata Declaration 1978 • Black Report 1980 • Ottawa Charter 1986 • Acheson Report 1998

24. Current Affairs • 2008 World Health Assembly – renewed interest in social determinants of health • US Health Reform: focus on prevention

25. 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

26. Thank you