Milbank Quarterly Classics

The (Still) Limited Contribution of Medical

Measures to Declines in Mortality
D AV I D A . K I N D I G

“M
edical measures appear to have contributed
little to the overall decline in mortality in the United
States since about 1900.” Readers might assume that this
statement is from a recent research article or policy report featuring the
social determinants of health. But no, it is from the 1977 seminal Mil-
bank Quarterly article by John and Sonja McKinlay titled “The Ques-
tionable Contribution of Medical Measures to the Decline of Mortality
in the United States in the Twentieth Century.”1
John McKinlay is a medical sociologist and epidemiologist, and Sonja
is a mathematical statistician. They both ended their full-time careers
leading the New England Research Institutes. Natives of New Zealand,
they both received doctorates at the University of Aberdeen in Scotland.
While working in the United Kingdom, they were exposed to the En-
glish and Welsh research of Thomas McKeown, and at ages 35 and 34,
wondered whether his thesis that specific medical measures had little
effect on overall mortality declines also applied in the United States.
In 2008, John received the American Sociological Association Distin-
guished Career Award for the Practice of Sociology. That award cited his
use of “sociology to identify gaps in literature, frame new research ques-
tions, and convince others of the importance of his ideas in areas others
may view as entirely unrelated to sociology.”
These qualities were evident when I first read their 1977 article in
1995 while writing my sabbatical book, Purchasing Population Health:
Paying For Results, in which I reproduced two of its figures. Figure 2
remains a striking image and illustrates their major line of evidence
that declines from 1990 to 1973 in US all-cause mortality (primarily
from 11 infectious diseases) had already bottomed out before increases
in health care spending began its dramatic escalation. For the five
infectious diseases that showed a mortality impact after interventions
were introduced (influenza, pneumonia, diphtheria, pertussis, and
The Milbank Quarterly, Vol. 98, No. 4, 2020 (pp. 1053-1057)
© 2020 Milbank Memorial Fund

1053
1054 D.A. Kindig

poliomyelitis), there was only a 3.5% contribution to the decline in

total mortality over this period.
The McKinlays then asked the question “if they [medical measures]
were not primarily responsible for it [the decline in mortality], then how
is it to be explained?” They did not answer this question themselves, but
referred back to McKeown, who had concluded that “the main influences
were: (a) rising standards of living, of which the most significant fea-
ture was a better diet; (b) improvements in hygiene; and (c) a favorable
trend in the relationship between some micro-organisms and the human
host.”2 However, in their conclusion they magnified this point, stating
that “profound policy implications follow from either a confirmation or
a rejection of the thesis. If one subscribes to the view that we are slowly
but surely eliminating one disease after another because of medical in-
terventions, then there may be little commitment to social change and
even resistance to some reordering of priorities in medical expenditures.
Hopefully, this paper will serve as a catalyst for such research, incorpo-
rating adequate data and appropriate methods of analysis, in an effort to
arrive at a more viable alternative explanation.”
As surprising as this may have been in 1977, it is even more shocking
that the question has not yet been adequately answered. Of course, the
analysis today would be different, as deaths from chronic diseases have
replaced the impact of infectious diseases of that period, which they
showed in Figure 3, and “managing” these diseases may now be more
important than “eliminating” them. But, in what I consider to be the
seminal paper in the modern field of population health science, only
one italicized sentence regarding the contribution of medical measures
appeared: “A society that spends so much on health care that it cannot or
will not spend adequately on other health enhancing activities may actually
be reducing the health of its population.”3 The authors, however, made no
empiric estimate regarding what this adequate fraction should be.
For many years, I taught a session of my population health course
featuring the two contemporary papers that frame what we know
today—the first by McGinnis and colleagues,4 based on CDC surveys,
argues that medical care is responsible for about 10% of preventable
mortality, and the second an econometric analysis by David Cutler5 ar-
gues that medical care was responsible for 50% improvement in certain
causes of mortality over the period of 1960 to 2000. When students are
shocked by this range, I remind them that, in a world that still predom-
inantly assumes the pre-McKinlay reality of medical care being close to
The Limited Contribution of Medical Measures to Mortality 1055

fully responsible for preventing or curing disease and death, it is still

a profound statement to many that much more than medical care goes
into the production of health.
In a 2007 Milbank Quarterly article, I asserted that “the overriding
population health question is, What is the optimal balance of invest-
ments (e.g., dollars, time, policies) in the multiple determinants of
health (e.g., behavior, environment, socioeconomic status, medical care,
genetics) over the life course that will maximize overall health outcomes
and minimize health inequities at the population level?” This is a sig-
nificant challenge that will require decades of attention by scholars and
policymakers.”6
One of my major disappointments at age 80 is that more policy rele-
vant answers have not emerged. Progress can be made even with current
understanding, as shown by the impact of the County Health Rank-
ings model (https://www.countyhealthrankings.org) that uses as a start-
ing point a 20% weight for medical care impact on a broad health
outcome mix of mortality and morbidity. It may be that our methods
and especially robust longitudinal data are inadequate for more com-
plete causal understanding. From this perspective, Greg Stoddart in
1995 called it the Fantasy Equation, arguing that “at present we but
vaguely understand the relative magnitude of the coefficients on the
independent variables that would inform specific policies rather than
broad directions, even if we are beginning to see the variables them-
selves more clearly“7,8(p344) and that more careful context-specific stud-
ies are required. But I refuse to accept that increased and badly needed
policy relevant results would not emerge from much more significant
investment in data infrastructure rather than having wasted and ineffec-
tive medical care dollars consume those resources,9 such as that recently
shown by Milstein and Homer.10
It should be noted that some anti-vaccine advocates have used the
McKinlays’ paper as scientific support for their views. To this, the
McKinlays reply that “we consider this an egregious misinterpretation
of our research. Effective vaccines clearly have an important role in the
ongoing containment of a disease after its prevalence has been reduced.
Measles provides an excellent current example of the resurgence of a pre-
viously contained infectious disease following reduction in measles vac-
cination interventions.” However, they add, in supporting basic public
health measures, that “if the current coronavirus follows the established
course of the several infectious diseases of the past that we examined,
1056 D.A. Kindig

then promising therapeutics or vaccines will have little effect on any

overall decline in the disease.”
The question they posed in 1977 is still fundamental to modern pop-
ulation health scholarship. I would add now a second applied question:
once pieces of the Fantasy Equation are better understood, how can we
create financial and other incentives for effective health enhancing cross-
sectoral collaboration and reinvestment? The November 2020 special is-
sue of the American Journal of Public Health features substantial analysis
and commentary on the challenges for achieving the 2012 Institute of
Medicine recommendation to reach parity with other OECD nations in
both health outcomes and health expenditures to improve the public’s
health.11
In conclusion, I remain grateful for the McKinlays’ ahead-of-its-time
article and for its ongoing relevance. But my hope (and concern) is that
it doesn’t take another 40 years for significant scholarship and policy
progress to be made on this most critical population health challenge.

References
1. McKinlay JB, McKinlay SM. The Questionable Contribution of
Medical Measures to the Decline of Mortality in the United States
in the Twentieth Century. Milbank Q. 1977;55(3):405-428.
2. McKeown T, Record RG, Turner RD. An interpretation of the
decline of mortality in England and Wales during the twentieth
century. Population Studies. 1975;29:391.
3. Evans R, Stoddart GC. Consuming healthcare, producing health.
Soc Sci Med. 1990;33:1347-1363.
4. McGinnis M, Williams-Russo P, Knickman J. The case for more
active policy attention to health promotion. Health Aff (Millwood).
2002; 21(2):78-93.
5. Cutler DM, Rosen AB, Vijan S. The value of medical spending in
the United States, 1960–2000. N Engl J Med. 2006;355:920-927.
6. Kindig DA. Understanding population health terminology. Mil-
bank Q. 2007;85(1):139-161.
7. Stoddart G. The challenge of producing health in modern
economies. Centre for Health Economics and Policy Analysis
Working Paper Series 1995-15, Centre for Health Economics
and Policy Analysis (CHEPA), McMaster University, Hamilton,
Canada; 1995.
8. Stoddart GL, Eyles JD, Lavis JN, Chaulk PC. Reallocating re-
sources across public sectors to improve population health. In:
The Limited Contribution of Medical Measures to Mortality 1057

Heymann SJ, Hertzman C, Barer M, Evans RG, eds. Healthier

Societies: From Analysis to Action. Oxford University Press;
2006:327-347.
9. Kindig D, Mullahy J. Comparative effectiveness-of what?
Evaluating strategies to improve population health. JAMA.
2010;304(8):901-902.
10. Milstein B, Homer J. Which priorities for health and well-being
stand out after accounting for tangled threats and costs? Simulat-
ing potential intervention portfolios in large urban counties. Mil-
bank Q. 2020;98(2):372-398.
11. McCullough JM, Spee, M, Magnan S, et al. Reduction in US
Health Care Spending Required to Meet the Institute of Medicine’s
2030 Target. Am J Public Health. In press.

Address Correspondence to: David A. Kindig, MD, PhD, University of Wisconsin-

Madison School of Medicine and Public Health, 610 Walnut Street, 575 WARF,
Madison, WI 53726 (email: dakindig@wisc.edu).