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

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The McKeown Thesis and Public HealthTime for a
Dignified Burial?

• Dr Gracia Fellmeth
• Specialty Registrar Public Health
• Oxford Deanery

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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

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Thomas McKeown (1912-1988)
Source BMJ 1988 297 129
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McKeowns Question
Source United Nation World Population Prospects
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McKeowns 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

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McKeowns 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

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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.h
tml).
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McKeowns 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

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McKeowns 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

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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

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Criticism

• Primary data
• Numerator vs denominator incompleteness
  misclassification
• Methodology
• Vague terminology infection vs mortality
  Holmesian approach
• Interpretation
• Background trends conclusions drawn

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• So is it time to bury McKeown?

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McKeowns Relevance

• Technical Relevance
• Aspects of his theory remain correct
• Conceptual Relevance
• His approach way of thinking remain important

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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

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

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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

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

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• The first difficulty is to see
• that there is a difficulty.
• Bertrand Russell

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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

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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 Lalondes Health Field Concepts,
1974
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Indirect Influence

• WHO Alma Ata Declaration 1978
• Black Report 1980
• Ottawa Charter 1986
• Acheson Report 1998

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Current Affairs

• 2008 World Health Assembly renewed interest in
  social determinants of health
• US Health Reform focus on prevention

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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 McKeowns ideas required to continue
  improving population health

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• Thank you