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 MortalityScarlet Fever Mortality Smallpox MortalityDiphtheria Mortality Redrawn from McKeown (1976) by Gherardi (nfs.unipv.it/nfs/minf/dispense/immunology/immun.html).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