The contribution of medical care to mortality decline: McKeown revisited

Abstract

In St. James’s Church (Sussex Gardens, London, U.K.) there is a stained glass window, which shows Sir Alexander Fleming at work in his laboratory. Fleming’s laboratory was located in the vicinity of this church, and it was there that he discovered the hactericida1 effects of penicillin. This church window perhaps is an illustration of the almost religious role of medicine in our modern society. In any case, it shows a deep respect for the advances of medicine, which in the popular opinion has become a master of life and death. The contrast hetween this popular opinion and the current scientific view of the effects of medical care on the health of populations is enormous. This is due to a large extent to the work of the late Thomas McKeown. His famous analyses of the history of mortality in England and Wales, which originally appeared in a number of journal articles, were summarized in 1976 in two hooks, of which The Role of Medicine--Dream, Mirage or Nemesis has heen very influential [I ,2]. In this hook he showed that the decline in mortalit) since the middle of the nineteenth century was the result main11 of a decline in mortality from infectious diseases. The latter decline for the most part antedated the introduction of specific medical therapies, including Fleming’s penicillin. From these analyses McKeown has drawn two conclusions, which both have generally heen accepted by the scientific community, particularly hy epidemiologists. The first was that medical care has not made a substantial contribution to mortality decline since the middle of the nineteenth century. The second, and more far-reaching, conclusion was that today’s health problems are also more likely to be controlled by changing the environment than hy medical care. Since the publication of McKeown’s findings important criticisms have been voiced, which together with more recent evidence suggest that some modifications of these conclusions may be necessary. The objective of this article is to review McKeown’a analysis and the more recent evidence, and to investigate whether the scientific opinion should or should not he reshifted a hit toward the popular opinion. Throughout this article data from The Netherlands, a country with abundant data of relatively high quality, are used as illustrations.