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© 2003 American Public Health Association
LETTER |
Correspondence: Requests for reprints should be sent to Simon Szreter, PhD, St John’s College, Cambridge CB2 1DY, England (e-mail: srss{at}cam.ac.uk).
I hope that my piece on McKeown has not so much missed his essential message as disputed it. My thesis is that it has been political and ideological forces that have primarily determined when and where human societies have chosen to use or not to use their technical and organizational skills to enhance the health of the majority. Far from technical developments’ having taken over from social determinants, the dominant influence remains political choices, such as those made by the citizens of today’s most powerful nations and their representatives with regard to, for instance, responses to climate change or the conditions on which AIDS drugs are made available to the poorest continent.
As I stated, McKeown successfully pinioned the scientific medical establishment of his day, and his permanent achievement has been to deny "the use of the past" as a rhetorical resource with which to inflate that establishment’s claims to a long history of life-saving achievements.
However, I continue to believe that Thomas McKeown, a great man and a gifted communicator, was nevertheless guilty of recklessness in driving home his iconoclastic conclusion. As demonstrated by his use of the undiscriminating phrase "medical advances," which Lawson cites, McKeown failed to adequately acknowledge the crucial importance of a whole range of other advances: preventive, public health, sanitary, and local government investments and services (such as inspection of foodstuffs, without which the increased food supply emphasized by McKeown would have had little net health benefit for the urban poor).
This vast range of measures and activities brought urban populations in the Western world to historically unprecedented health levels by the beginning of the 20th century. Little of it was the medical equivalent of rocket science, but all of it required the political campaigning and agency of that poorrelation branch of the medical profession, the historic public health movement.1–5 Along the way, the urban populace became re-educated with the health-related knowledge that Lawson rightly values.6,7,8 Cleanliness may have been appreciated by the poor, but regular washing became a practical possibility only with the political resolve by municipalities to supply all domiciles, regardless of capacity to pay, with a regular, clean water supply and the fittings and fixture to receive the supply. This was something the public health movement had to push for endlessly because of the obvious expense to reluctant middle-class taxpayers. In an age of imperialist perceptions, this political will did not extend in the same measure to the poor peoples of other continents—nor does it yet.7,9–12
References
1. Rosenkrantz BG. Public Health and the State: Changing Views in Massachusetts, 1842–1936. Cambridge, Mass: Harvard University Press; 1972.
2. Leavitt JW. The Healthiest City: Milwaukee and the Politics of Health Reform. Madison: University of Wisconsin Press; 1982.
3. Szreter S. The importance of social intervention in Britain’s mortality decline c. 1850–1914: a reinterpretation of the role of public health. Soc Hist Med.1988;1:1–38.
4. Hardy A. The Epidemic Streets: Infectious Disease and the Rise of Preventive Medicine 1856–1900. Oxford, England: Clarendon Press; 1993.
5. Szreter S. Economic growth, disruption, deprivation, disease and death: on the importance of the politics of public health for development. Popul Dev Rev.1997;23:693–728.[Web of Science]
6. Tomes N. The Gospel of Germs: Men, Women and the Microbe in American Life. Cambridge, Mass: Harvard University Press; 1998.
7. Sheard S. Profit is a dirty word: the development of public baths and wash-houses in Britain 1847–1915. Soc Hist Med.2000;13:63–85.[Abstract]
8. Powles J. Healthier progress: historical perspectives on the social and economic determinants of health. In: Eckersley R, Dixon J, Douglas B, eds. The Social Origins of Health and Well-Being: From the Planetary to the Molecular. Melbourne, Australia: Cambridge University Press; 2001:chap 2.
9. Watts S. Epidemics and History: Disease, Power and Imperialism. New Haven, Conn: Yale University Press; 1997.
10. Farmer P. Infections and Inequalities: The Modern Plagues. Berkeley: University of California Press; 1999.
11. Davis M. Late Victorian Holocausts, El Niño, Famines and the Making of the Third World. London, England: Verso Press; 2001.
12. Vaughan M. Curing Their Ills: Colonial Power and African Illnesses. Stanford, Calif: Stanford University Press; 1991.
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