Thomas McKeown (physician)

McKeown was born in Portadown, Northern Ireland and then moved to Vancouver, Canada with his parents. During wartime, he studied medicine at London University where he obtained a Bachelor in Surgery in 1942. In the early 1940s, the Nuffield Provincial Hospital Trust offered to finance a chair of social medicine at the newly founded University of Birmingham McKeown was appointed in 1945 as professor, not yet 33 years old, and held the chair until his retirement in 1977. In Birmingham, he also did his MD graduation in 1947. He is also known for his work in geriatrics and maternal-fetal medicine. He was a consultant for the World Health Organization, Josiah Macy Foundation, Commonwealth Fund, and Rockefeller Foundation. He died in 1988, and was survived by his wife Esmé and their son and daughter. ==Scientific contribution==

McKeown developed his theories over a period of more than three decades between 1955 and shortly before he died in 1988. The seeds of his work can be found in four seminal papers published in the academic journal Population Studies, and a textbook (with C.R. Lowe) An Introduction to Social Medicine from 1966. These earlier publications did not attract much attention beyond the academic community until he merged these publications in two controversial books: The Modern Rise of Population and, endowed by a Rock Carling Fellowship of the Nuffield Trust, a lecture with the provocative title The Role of Modern Medicine: Dream, Mirage or Nemesis? In his last book, The Origins of Human Disease, published shortly after he died in 1988, he had found a milder tone to express his critical relativism of medicine and health. Here he had found the right balance between responding to legitimate criticism of the limitations of his thesis, without showing much mercy for unjust critics. McKeown challenged four theories about the increase of the western population since the 18th century: • McKeown stated that the growth in population, particularly surging in the 19th century, was not so much caused by an increase in fertility, but largely by a decline of mortality particularly of childhood mortality followed by infant mortality, • The decline of mortality could largely be attributed to rising standards of living, whereby he put most emphasis on improved nutrition, • His most controversial idea, at least his most disputed idea, was that he questioned the effectiveness of public health measures, including sanitary reforms, vaccination and quarantine, • The sometimes very fierce disputes that his publication provoked around the "McKeown thesis", have overshadowed his more important and largely unchallenged argument that curative medical measures played little role in mortality decline, not only prior to the mid-20th century but also until well into the 20th century. ==Influence and criticism==

The publication of The Modern Rise of Population (1976) provoked instant disagreement by demographers, but also yielded much acclaim from health critics. In the 1970s, an era wherein all aspects of social, economic and cultural establishment were challenged, McKeown found a receptive audience with other health critics such as Ivan Illich. By some researchers, including the economist and Nobel prize winner Angus Deaton, McKeown is considered as the founder of social medicine. McKeown's work continued to attract criticism for decades after his death in 1988. Sometimes his conclusions were criticised in mild terms: ‘His great virtue was to ask the right questions. He did not always provide the best answers.’ McKeown repeatedly urged readers to rethink public health, medical care and social policy, implying that this would have political and financial benefits. The debate over the McKeown thesis has however been criticized as providing no such benefits. McKeown’s supporters supposedly ‘feel a continuing need for a McKeown peg on which to hang their hat, while others want a McKeown target at which to aim their darts.… Perhaps it is time to conclude that this cycle of thesis, antithesis, and synthesis has been played out, to give the ‘McKeown debate’ a dignified burial and to move on to other things.’ What makes it even more complicated to value McKeown's work and its consequences is that he himself shaped and reshaped his ideas in a career that spans more than five decades, from his first publication in 1934 to his last book on The Origins of Human Disease in 1988. and Angus Deaton (2015) have greatly contributed to the recent reappreciation of the McKeown thesis: McKeown's views, updated to modern circumstances, are still important today in debates between those who think that health is primarily determined by medical discoveries and medical treatment and those who look to the background social conditions of life. (Angus Deaton, page 91) == Theses ==

Population growth for data since 1900) Nowadays, very few will disagree with McKeown that the late 19th century surge of the population in the western world can be mainly ascribed to a fall in mortality and not to a rise in fertility. This was not that evident when he first published The Modern Rise in Population in 1976. Benson (1976) in a critical review of his book wrote that McKeown had insufficiently shown that it was mortality that fell and not fertility that rose to cause the population growth. In 1981, Wrigley and Schofield published an authoritative study on The Population History of England 1541–1871. Among many valuable findings on historical demography, and for the pre-industrial time largely based on studies of parish registers, they may in hindsight have overinterpreted the frequent birth peaks as evidence that an increase of the birth-rate was the predominant influence before the mid-nineteenth century. Already in 1974, Flinn described that such birth peaks were usually preceded by a period of mortality crises; however, as Flinn extensively describes, in times of turmoil deaths may not always have been accurately registered. Furthermore, as McKeown explained, it is very hard to biologically understand how a higher standard of living in early industrialisation could have selectively favoured fertility without decreasing mortality. Although he may have been unduly critical by stating that I should therefore explain that I do not think there is any treatment of the deficient material from the registers that would make it reliable [McKeown, 1988, page 9], his criticism was well taken. The authors also appreciated the pre-industrial demographic patterns characterised by mortality peaks followed by fertility boosts. They however explained the initial phase of the population growth during the transition from late agricultural to early-industrial civilisation not so much by a decrease in mortality, as McKeown's had postulated, but by a stabilisation of mortality as Flinn (1974) called it. started in Britain in the late 18th century and on the European continent about a half century later. Still in 2002, some critics of McKeown described this demographic controversy as one of his many flaws,|297x297px Wealth and health: nowadays it is hard to imagine that only forty years ago there were scientists who doubted seriously that an increased standard of living was the main drive behind the growth of population, better health and a longer life expectancy. This doubt was probably cast by an idealisation of the living conditions of pre-historical hunters and gatherers, or by a nostalgic call for a return to the flower power of ancient agricultural life. This became known as the Malthusian trap. That Western population grew despite the vices of industrialisation was one of the main arguments why McKeown put so much emphasis on one of the few virtues of early industrialisation: the country was able to produce and provide more and better food for the people. Flinn (1971) already found for the pre-industrial 18th century that mortality crises were less than in the 17th century, and explained that by reduced fluctuations in food prices and fewer and less severe periods of famine by increased food imports during periods of failed crops, and by an agricultural transition from monoculture (grain) to more diverse products (rice, maize and buckwheat in the south, and potatoes in the north).|294x294px Since McKeown first proposed his thesis, several historians of economics have gathered supportive evidence for the McKeown thesis. Up to about 1898, changes in the biological standard of living were closely related to changes in the availability of food. After ~1898, the curves start to diverge: although the average caloric intake did not further increase, both body-length and life expectancy did increase until 1940. This also corroborates McKeown's assertion that public health measures started to boost the well-being of the population during the 20th century. However, the strong correlation between calorie intake and longevity is not a proof that nutrition was the only reason for the decline of mortality, although it is an indispensable condition. As Angus Deaton concluded (page 92): but that other environmental improvements which came with more wealth, i.e. hygienic measures, had to work at the same time. Many studies gave convincing arguments that Public Health measures such as better housing, clean water supply, sewage and sanitation, vaccination and health education improving personal hygiene may, in western Europe, have become increasingly important since the end of the 19th century. McKeown himself, in The Origins of Human Disease, fully acknowledged this 20th century role of Public Health. A semantic problem, as pointed out by Simon Szreter (2002), is that Public Health is a poorly defined field of medicine in the twilight zone between the responsibility of the state or government and health care provided by physicians and nurses. The drilling of clean water wells, the construction of sewage systems, and legislation resulting in better housing, better education and improved working conditions is in most countries the responsibilities of the state, and it is surely not a good idea to make a public health professional responsible for the drilling, masonry and the enforcement of housing regulation. McKeown was not a politician, and it is quite absurd to hold him responsible for the virtual dismantlement (of public health) during the last 2 decades of the 20th century. that the mortality reduction from vaccines was marginal, and that from antibiotics could not be demonstrated. McKeown gave similar results for England and Wales, showing that the mortality from infectious diseases was already so very low by the time that these treatments were introduced in medical practice, that they have contributed little to the reduction of overall mortality and the population growth. An example that he repeatedly used was the falling mortality from tuberculosis in England and Wales since the 19th century, well before the introduction of the first effective antibiotic drug in 1947 and BCG vaccination in 1954. By the time of the introduction of streptomycin, the first effective antibiotic drug, in 1947 and BCG-vaccination in 1954, the mortality rate from tuberculosis had already dropped to 33,1 per 100,000, a 91% decrease. However, he found that specific age groups did show an accelerated decrease in mortality after introduction of streptomycin. Remarkably, the authors of this Dutch study considered their results as evidence that McKeown's theory was wrong, and the study is therefore frequently cited to refute instead of confirm McKeown's thesis. ==Books==

• McKeown, Thomas. Medicine in Modern Society: Medical Planning Based on Evaluation of Medical Achievement. George Allen & Unwin Ltd, London, UK, 1965 • McKeown, Thomas, and Lowe, C.R. An Introduction to Social Medicine. Blackwell Scientific Publications, Oxford and Edinburgh, Uk, 1966. • McKeown, Thomas. The Modern Rise of Population. London: Edward Arnold, 1976 • McKeown, Thomas. The Role of Medicine: Dream, Mirage, or Nemesis? Princeton University Press (Princeton Legacy Library), 1980. Previously, “The role of medicine: Dream, mirage or nemesis?” The Rock Carling Fellowship, 1976. The Nuffield Provincial Hospitals Trust, London UK, 1976 report for the Nuffield Trust • McKeown, Thomas. The Origins of Human Disease. Oxford: Basil Blackwell, 1988. ==References==