462507

Journal of Public HealthLow et al

APH24510.1177/1010539512462507Asia-Pacific

Editorial
Asia-Pacific Journal of Public Health

Thomas McKeown:  A true 24(6) 893­–895

© 2012 APJPH
Reprints and permission:
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DOI: 10.1177/1010539512466632
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Colin Binns, MBBS, PhD1,

Seung Wook Lee, Graduate, DrPH2, and Wah-Yun Low, PhD3

In the last half of the 20th century, the United Kingdom produced several great social medicine
and epidemiology scholars, who had and still has a substantial influence on public health learn-
ing and practice. Perhaps, the best known was Prof Archie Cochrane whose name lives on in the
Cochrane Reviews. Another great scholar was Sir Richard Dole who made a major contribution
to epidemiology particularly through his contribution to understanding the impact of smoking
on health.
Perhaps, a little less well-known was Thomas McKeown (1912—88) who was appointed as
the Professor of Social Medicine at the University of Birmingham in 1945. As the story goes, he
had applied for the Chair of Anatomy the year before. He had apparently impressed the appoint-
ment committee with the quality of his application. It seems hard to believe in the current atmo-
sphere of competition for University appointments. But a year later, he was offered the Chair of
Social Medicine. He quickly became interested in the relationships between the growth of
populations, public health and nutrition.
The writings of McKeown and Cochrane and to a lesser extent, the more radical Ivan Illich,
triggered a debate that still continues about the appropriate balance between medical treatment
and public health in a broader social context. The debate in the 1960s and 70s culminated in the
WHO declaration of “Health for All” at Alma Ata in 1977, a relatively toothless resolution, but
it did coin the term “health for all” which is the basis for modern public health and global health
initiatives. 1-3
The two books that had most influence on public health in this period were The Role of
Medicine: Dream, Mirage or Nemesis by McKeown4 and Effectiveness and Efficiency: Random
Reflections on Health Services by Cochrane.5 Cochrane advocated the more systematic evalua-
tion of science and guided the implementation of health interventions. He emphasised the impor-
tance of randomised controlled trials and of course his name persists in the formal process of
systematic reviews that bears his name. McKeown is best known for his interpretation of demo-
graphic trends and looking for causes of population growth. He concluded that the benefits of
medical care had been overemphasised and the improved nutrition played an important role in
population growth.
In his 1972 article, McKeown described three possible mechanisms for the decline of mortal-
ity in the European countries that he studied: namely Sweden, France, Ireland and Hungary. He
concluded that the reasons for the decline in mortality and growth of population were due to (a)
a rising standard of living, of which the most significant feature was improved diet; (b) the

1
School of Public Health and Curtin Health Innovation Research Institute, Curtin University, Perth, Western Australia
2
Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea
3
Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

Corresponding Author:
Wah-Yun Low, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
Email: lowwy@um.edu.my
894 Asia-Pacific Journal of Public Health 24(6)

hygienic changes introduced by the sanitary reformers; and (c) a favourable trend in the relation-
ship between infectious agent and the human host. The effect of therapy was restricted to small-
pox and hence had only a trivial effect on the total reduction of the death rate.6 But he seems to
be expressing some doubt about the extent of the relationship between nutrition and infection,
and he states “it is difficult to determine to what extent the illness results from lowered nutrition
or increased exposure.”6
Link & Phelan7 summarise McKeown’s thesis in the following way: “that the enormous
increase in population and dramatic improvements in health that humans have experienced over
the past two centuries owe more to changes in broad economic and social conditions than to
specific medical advances or public health initiatives. The thesis gives center stage to social
conditions as root causes of the health of populations.”
Following the publication of McKeown’s work on population, he was widely criticised by
demographers, and at the time his social medicine colleagues seem to have stayed out of print.
Two decades later, Colgrove reviewing his legacy states “his work generated considerable con-
troversy in the 1970s and 1980s, and it continues to stimulate support, criticism, and commen-
tary to the present day, in spite of his conclusions’ having been largely discredited by subsequent
research.8 After stating that empirical evidence has laid McKeown’s thesis to rest, Colgrove then
goes on to postulate why he remains popular: “What accounts for his work’s remarkable durabil-
ity? Why has the influence of the McKeown thesis persisted even after its conclusions were
discredited? In part, his writing continues to generate responses because many scholars believe
that although McKeown’s analysis was flawed, his underlying ideas regarding the effects of
poverty and economic wellbeing on health were essentially correct. More broadly, McKeown’s
influence has continued to be felt because his research posed a fundamental question that has
lost none of its relevance in the decades since he began writing in the post–World War II era:
Are public health ends better served by narrow interventions focused at the level of the indi-
vidual or the community, or by broad measures to redistribute the social, political, and economic
resources that exert such a profound influence on health status at the population level?”
Colgrove could not have summarised the contemporary interest in the social context of pub-
lic health in a better way.9 In the same issue of the American Journal of Public Health, Link
explains where Colgrove and his fellow critics have gone wrong: “Criticisms of McKeown
focus on his minimizing the role of public health and medical interventions, not on the idea that
an expansion of economic resources led to improved nutrition and better health. This eminently
reasonable aspect of his thesis alerts us that factors not typically conceptualized as relevant to
health can have tremendous impacts on health outcomes. Thus, we need to be mindful of the
potential health impact of the entire array of social, political, and economic policy we humans
develop, such as social security, child welfare, education, or the location of potentially polluting
industries.” 7
The science of nutrition has made great advances since McKeown began his work and we are
now aware of the value of adequate nutrition in reducing rates of nutrition and infection.10-12
Further our understanding of the ‘Developmental Origins of Adult Disease Hypothesis and our
understanding of epigenetics have shown the importance of early nutrition in programming for
a long and healthy life.13-15 The effects of under-nutrition in early life are further compounded
by the influence of over-nutrition, including obesity in adulthood leading to the current epidemic
of chronic disease in the Asia Pacific region.16
This year it is 100 years since the birth of Thomas McKeown and 50 years since he first
published his theories of population growth.6 Next year will be the 25th anniversary of his death.
Modern advances in public health and in nutrition have shown how nutrition influences both
infectious chronic diseases. Anthropometric data and food balance studies have documented the
improvement of nutrition in the Asia Pacific region. Perhaps, we can agree with some of
McKeown’s critics – he may have relied on flawed data, but modern science has justified his
Binns et al. 895

conclusions about the role of nutrition in population disease and conversely in population
growth.

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