Thirty years on, most workers in the field would agree in broad terms with Mc Keown’s hypothesis.
Nevertheless, his theory has been refined and updated, and most theories advanced in recent years see the provision of health care as at least a part of the explanation for better health.
Originally published in 1976, Professor Thomas Mc Keown’s influential book The role of medicine – dream, mirage or nemesis?
put forward a formidable and convincing argument to the effect that health care itself made only a minor contribution to the massive improvements in population health between the mid-nineteenth and mid-twentieth century in the developed world.
Fortunately there is a substantial international literature that deals with this point, and it is to this literature that we turn now. 8 For a concise examination of the social determinants of health, see Wilkinson, R. 12 We note, for example, how following the 1989 National Aboriginal Health Strategy in Australia, there was a powerful emphasis in national public policy on the need for better infrastructure – especially improved housing, water quality and sanitation – as the way to make progress in Aboriginal health, almost to the detriment of the provision of health services at all.
The work of Thomas Mc Keown in the 1970s and more recently, substantial evidence of the importance of the social determinants of health, have critically challenged the ‘common-sense’ idea that improved population health is simply the result of better health care. This is of course was very different to the intent of the Strategy. His controversial hypothesis helped revolutionise how the health of populations was viewed.In the last fifteen years or so, a whole new theory and field of research has grown up that, like Mc Keown’s hypothesis, locates the major factors determining the health of populations outside the health care system, but which goes much further in exploring and documenting these factors.It is simply assumed to be true, and a considerable amount of public and political discourse in Australia is based on the more-or-less uncritical adoption of this view.However, there have been serious challenges to this apparently obvious assumption.The first transition occurred with the shift to agriculture about 10,000 YBP, resulting in a pattern of infectious and nutritional diseases still evident today.In the last two centuries, some populations have undergone a second transition, characterized by a decline in infectious disease and rise in degenerative disease.While explanations of illness cast in terms of exposure to certain individual risk-factors (for example viruses, bacteria, smoking, alcohol misuse, or being overweight) are a powerful way of understanding disease and illness, considerable evidence has now emerged that in addition to these individual causes lie other deeper causative factors.These are, of course, the social determinants of health.Implications for health policy In locating the major drivers of health and ill health outside of the health system – whether in living standards or the broader social determinants of health – these theories and research findings have presented a major challenge to health systems and the health professions.Simply put, if poor health is largely driven by the issues of poverty, nutrition, education, life control, racism, housing, transport, addiction, employment and all the other social determinants, what role does the health system have in creating better health? "The contribution of medical care to mortality decline: Mc Keown revisited." J Clin Epidemiol 49(11): 1207-13.