November 3, 2020

On healthcare and its contribution to decline in mortality

 The (Still) Limited Contribution of Medical Measures to Declines in Mortality

The Questionable Contribution of Medical Measures to the Decline of Mortality in the United States in the Twentieth Century

 “Medical measures appear to have contributed little to the overall decline in mortality in the United States since about 1900.” Readers might assume that this statement is from a recent research article or policy report featuring the social determinants of health. But no, it is from the 1977 seminal Milbank Quarterly article by John and Sonja McKinlay titled “The Questionable Contribution of Medical Measures to the Decline of Mortality in the United States in the Twentieth Century.”

 In the section of Milbank Quarterly Classics, David Kindig explains his favourite topic while reviewing the McKinlays 1977 article:

 “if they [medical measures] were not primarily responsible for it [the decline in mortality], then how is it to be explained?” They did not answer this question themselves, but referred back to McKeown, who had concluded that “the main influences were: (a) rising standards of living, of which the most significant feature was a better diet; (b) improvements in hygiene; and (c) a favorable trend in the relationship between some micro‐organisms and the human host.”2 However, in their conclusion they magnified this point, stating that “profound policy implications follow from either a confirmation or a rejection of the thesis. 

 For many years, I taught a session of my population health course featuring the two contemporary papers that frame what we know today—the first by McGinnis and colleagues, based on CDC surveys, argues that medical care is responsible for about 10% of preventable mortality, and the second an econometric analysis by David Cutler argues that medical care was responsible for 50% improvement in certain causes of mortality over the period of 1960 to 2000. When students are shocked by this range, I remind them that, in a world that still predominantly assumes the pre‐McKinlay reality of medical care being close to fully responsible for preventing or curing disease and death, it is still a profound statement to many that much more than medical care goes into the production of health.

A must read. There are still many unanswered questions.