Introduction

Dr John Tatham of the General Register Office (GRO), looking back in 1905 over more than half a century' achievements by the public health movement since the passing of the first Public Health Act of 1848, found it necessary deprecatingly to remind his readers that “it will be well to utter a caution at this stage against the prevalent tendency to attribute to the results of sanitary administration alone the whole of the life-saving which has taken place.…” As most undergraduates today in medicine or modern history will know, it is now widely considered that this confidently expressed belief, that directed human agency informed by medical and sanitary science was the principal source of improvement in the nation' health, has apparently been deflated and debunked conclusively by the historical epidemiological research project of Professor Thomas McKeown and associates.

The strong currency that McKeown' new orthodoxy continues to enjoy was illustrated recently by a leading article in the British Medical Journal, which concluded that improving nutrition—the essence of the “McKeown thesis”—is still the best explanation we have for the historical fall in mortality in Britain. The main purpose of this chapter will be to argue that McKeown' analysis of the empirical data has been misleading and to show that closer attention to the crucial elements of his own quantitative evidence in fact confirms the essential spirit of Tatham' contemporary assessment.