Appendix 27 - The Receding Tide

by Michael Greger, MD and United Progressive Alumni

[ Medical School Resources | Appendices | Discussion ]

Historically, community-based, societally driven activities and changes in individual behavior have accounted for the vast majority of health gains - Alfred Summer, dean of the Johns Hopkins School of Public Health.

Eminent epidemiologist Thomas McKeown, former chairman of the World Health Organization Advisory Group on Health Research Strategy, has been described as "a prophet among us." He writes:

Medical practice, including such preventive measures as immunization, has had an almost insignificant role in the improvement of health.... In short, our medical care system has received more credit and more financial support than can be justified after critical appraisal of its effectiveness.[314],[315]

For example, although the introduction of streptomycin to treat tuberculosis reduced the number of TB deaths by 50%, the disease had so declined before the TB bug was even discovered (thanks to better nutrition, housing, sanitation) that overall medical treatment only accounted for 3% of the drop in mortality over about the last 150 years.[316] In fact, 3.5% probably represents a reasonable upper-limit estimate of the total contribution of medical measures to the decline in mortality in the United States over the last hundred years.[317] Pasteur's dying words reportedly included: "Bernard is right; the pathogen is nothing; the terrain is everything."

McKeown's theory on the whole has, "generally been accepted by the scientific community,"[318] and has been called "unquestionably right."[319] From the book The Mirage of Health, "When the tide is receding from the beach it is easy to have the illusion that one can empty the ocean by removing water with a pail."[320]


[314] McKeown, T. "The Road to Health." World Health Forum 10(1989):408-416.

[315] Godber, GE. "McKeown's 'The Role of Medicine.'" Milbank Memorial Fund Quarterly 1977(Summer):373-378.

[316] Beeson, PB. "McKeown's 'The Role of Medicine.'" Milbank Memorial Fund Quarterly 1977(Summer):365-371.

[317] McKinlay, JB and SM McKinlay. "The Questionable Contribution of Medical Measures to the Decline of Mortality in the United States in the Twentieth Century." Milbank Memorial Fund Quarterly 1977(Summer):405-428.

[318] Mackenbach, JP. "The Contribution of Medical Care to Mortality Decline." Clinical Epidemiology 49(1996):1207-1213.

[319] The Lancet 12 February 1977:354.

[320] Dubos, R. The Mirage of Health: Utopias, Progress, & Biological Change New Brunswick: Rutgers University Press, 1987:23.

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