To the common sense view, the proposition that better health is the result of better health care – more spending on health systems, more health care workers, more advanced drugs and treatments – is unarguable. 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 McKeown Hypothesis and the Social Determinants of HealthOriginally published in 1976, Professor Thomas McKeown’s influential book The role of medicine – dream, mirage or nemesis?6 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.
McKeown’s argument was based on the fact that between roughly 1850 and 1970, the greatest decreases in mortality and advances in life expectancy for particular diseases occurred before the introduction of improved medical treatments for those conditions. McKeown argued that these advances were actually the result of better nutrition associated with rising living standards. He even rejected any significant role for public health measures such as improved hygiene and sanitation, again because they only became effective after the decline in mortality was well underway.7
At the time of their first publication, McKeown’s theories flew in the face of accepted wisdom which saw scientific advance and better medicine as the principal drivers of better health. 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 McKeown’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.
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.8Top of page
According to the theory of the social determinants of health – a theory now powerfully supported by numerous studies and substantial evidence reviewed by the World Health Organization – a person’s social and economic position in society, their early life experiences, their exposure to stress, their educational attainment, their employment status, their exclusion from participation in society, and transport, all exert a powerful influence on their health throughout life.9
In Australia, there have been a number of studies over the past two decades that have demonstrated the link between socioeconomic status and mortality, and the literature on the social determinants of health of Australia’s Indigenous population is growing.10 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?
Health service providers and policy makers have had to deal with two common reactions to this challenge. On the one hand, all too often the reaction is to acknowledge the importance of these ‘upstream’ factors that so powerfully influence health, but then consign them to the background, as issues that are too hard to address and outside the responsibility of the health system.11
Alternatively, while neither McKeown nor the researchers and theorists on the social determinants of health claim that health care has no effect on the health of populations, there have been times when their implicit or explicit critiques of the ‘medical model’ have led some to abandon the belief that the health system has any effect on the health of populations at all.12Top of page
While neither of these reactions may be very useful or strategic, the question remains about the extent to which health services contribute to population health. Fortunately there is a substantial international literature that deals with this point, and it is to this literature that we turn now.
The work of Thomas McKeown 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.
Updating McKeown – the contemporary landscapeThirty years on, most workers in the field would agree in broad terms with McKeown’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. For example, in his highly influential book, Development as Freedom, Amartya Sen suggests that increases in life expectancy in 20th century Britain were particularly strong in those periods marked by a strong emphasis on social sharing, and the public provision of health care and nutritional support.13
It has also been convincingly argued that medicine, as well as having a greater direct effect than McKeown’s analysis gave credit for, also had an indirect beneficial effect on population health. This was felt through the actions of doctors and others trained in or influenced by medicine, advocating successfully for the development of public health measures and the adoption of healthier behaviours.14
Last, and of particular relevance to the contemporary situation, McKeown’s data only covered the period up to the 1960s. His analysis was based on a particular social, epidmiological and historical context, and the time since then has been marked by significant advances in health care treatments, technology and organisation. This has included, in particular, the development of safe and effective treatments for chronic disease, changes in the organisation of health care in developed countries (including, for example, the adoption of evidence-based medicine), the development of organised approaches to public health and the development of comprehensive primary health care.Top of page
Accordingly, there is now a general consensus that health care systems’ contribution to population health is far from negligible.
6 McKeown, T. (1979). The role of medicine - dream, mirage or nemesis? Oxford, Blackwell.
7 Mackenbach, J. P. (1996). "The contribution of medical care to mortality decline: McKeown revisited." J Clin Epidemiol 49(11): 1207-13, Nolte, E. and M. McKee (2004). Does healthcare save lives? Avoidable mortality revisited. London, The Nuffield Trust.
8 For a concise examination of the social determinants of health, see Wilkinson, R. and M. Marmot (1998). Social Determinants of Health: the Solid Facts, World Health Organization Regional Office for Europe.
9 World Health Organization (2003). Social determinants of Health: The Solid Facts, 2nd edition, Marmot, M and Wilkinson, R (eds.), International Centre for Health and Safety, Denmark.
10 See for example, Booth, A. and Carroll, N. (2005) The health status of Indigenous and non-Indigenous Australians, Discussion Paper No. 486, Centre for Economic Policy Research, ANU, Canberra, and their estimate that income, employment status and education accounted for between one-third and one-half of the gap in health status between Indigenous and non-Indigenous Australia.
11 Griew, R. and T. Weeramanthri (2003). Investing in Prevention and Public Health in Northern Australia. UK Australia Seminar: Federalism, Financing and Public Health. Canberra, The Nuffield Trust and Australian Government.
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. This is of course was very different to the intent of the Strategy.
13 Sen, A. (1999). Development as Freedom. New York, Alfred Knopf.
14 Mackenbach, J. P. (1996). "The contribution of medical care to mortality decline: McKeown revisited." J Clin Epidemiol 49(11): 1207-13.