The Importance of Social Intervention in Britain's Mortality Decline c.1850–1914: a Re-interpretation of the Role of Public Health

Abstract

It continues to be generally accepted that the iconoclastic research work of Professor Thomas McKeown and associates conclusively demonstrated that the medical establishment-including all the efforts of the public health movement-played only a minor role in the grand historical and demographic drama of the period, the secular decline in national mortality levels. According to McKeown's apparently authoritative analysis and interpretation of the available epidemiological statistics, the mortality decline in England and Wales can be primarily accounted for by the benevolent 'invisible hand' of gradually rising living standards, particularly in the form of increases in per capita nutritional consumption. The coherence of this view is brought into question by a critical re-examination of the supporting evidence and arguments presented by McKeown el al. It is anticipated that for many of those not closely acquainted with the 'McKeown thesis', the fragility of the case may come as something of a surprise. An alternative interpretation of the same epidemiological evidence then forms the basis for a revisionist account which directs attention to the leading role played by the public health movement and its locally administered preventive health measures in combating the urban congestion created by industrialization.

The Human Development Index, 1870-1999: Some revised estimates

“…Similarly, changes in publ ic health and education policies appear to have been substantially responsible for declining mortality and partly responsible for rising school enrolment and literacy in late nineteenth century Britain when HDI advanced strongly despite disappointing economic growth (Szreter, 1988;Mitch, 1986).…”

Are Modern Environments Really Bad for Us?: Revisiting the Demographic and Epidemiologic Transitions

“…McKeown (1976) concluded, after eliminating \all other possible causes" (a-c), that the cause of the decline must be improved nutrition, despite any hard evidence for or against this conclusion. This analysis suffers from several problems (Hinde, 2003;Szreter, 1989;Woods, 2000). First, his arguments against host-parasite interactions were based on the notion that host and parasite evolve to accommodate one another, and that evolution is slow.…”

Mortality versus morbidity in the demographic transition

“…It preceded the secular decline of child mortality. In fact it was the catalyst for aggressive public health initiatives that made possible the subsequent mortality transition (Szreter, 1988). Nineteenth century height gains were not unique to England (de la Croix and Licandro, 2013).…”

“…Prior to the pub- (Szreter, 1988). Improved sanitation and water management led to cleaner water supplies, food safety and effective sewage disposal.…”

“…1 Falling prevalence was behind the West's mortality transition and morbidity declined in tandem: child survival gains in late nineteenth century England and Wales were followed by secular gains in adult stature in successive cohorts (Szreter, 1988 In the model when child mortality falls from lower prevalence, more surviving children are of better quality (health), which raises the return to investing in their education as long as rearing sick children is not too time intensive. Altruistic parents substitute toward child quality; the total and net fertility rates fall.…”