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The McKeown Thesis and Public Health: Time 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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McKeown’s Question Source: United Nation World Population Prospects
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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
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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
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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
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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
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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
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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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McKeown’s 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 Lalonde’s 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 McKeown’s ideas required to continue improving population health
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Thank you
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