I’ll start with one of the most compelling graphs I’ve come across in this area: Thomas McKeown’s depiction of tuberculosis mortality in England over the last 150 years.
This echoes the conclusions Rudolf Virchow made over a century prior, when commissioned by the Prussian government to investigate a typhus outbreak in Upper Silesia. Virchow astonished his commissioners by pronouncing the outbreak an “artificial” epidemic, faulting the elites for their neglectful social and economic policies. Virchow’s report includes perhaps my favorite medical recommendation: “full and unlimited democracy.” Because, according to Virchow, “medicine is a social science, and politics is nothing else but medicine on a large scale.”
In practice however, this dichotomy is also artificial. And as any Haitian grann will tell you, we must expand our capacity for complexity.
It is important to note that McKeown’s thesis has been lambasted in recent decades, with more robust analyses like Arthur Nesholme’s gaining credence among medical historians. Nesholme argued that the 1834 Poor Law, which quarantined destitute TB patients from workhouses, served as a key component to declining TB mortality, as it had the unintentional effect of increasing early diagnosis and preventing TB spread to the general population. Thus medical and public health interventions (intentional or otherwise) do have a role to play. What I think can be mutually concluded from Nesholme and McKeown is two-fold:
- Poverty or inequity is a salient underlying characteristic in both analyses; whether as a key target population in Nesholme, or as a target in and of itself for McKeown.
- Targeted health interventions and those focused on systemic change don’t exist in opposition, but rather as “essential complements to each other.”