Tuberculosis mortality in England and Wales fell to a small fraction of its mid-nineteenth-century level before streptomycin existed. When the drug finally arrived in 1947, it accounted for approximately 3.2% of the total decline recorded since 1848. Measles, whooping cough, and scarlet fever collapsed before any effective treatment was available. The Netherlands never ran a national BCG programme and had the lowest European tuberculosis death-rates in both 1957-59 and 1967-69. These are the kinds of findings that fill The Role of Medicine: Dream, Mirage or Nemesis?, Thomas McKeown’s 1979 revision of his Rock Carling Lecture, and they settle a question most people assume was settled the other way: medicine did not end the plagues. Something else did, and medicine arrived in time to be credited with work it had not performed.
Thomas McKeown was Professor of Social Medicine Emeritus at the University of Birmingham. He trained in biochemistry at McGill and in human anatomy at Oxford before entering clinical medicine at a London teaching hospital, where the gap between the elaborate diagnostic apparatus and the therapeutic benefit to the patient first provoked his doubts. He worked for thirty-three years with Professor R.G. Record on the demographic history of population growth, producing The Modern Rise of Population in 1976. His conclusions emerged from decades of statistical analysis rather than from polemic, and the Rock Carling Lecture that became this book was addressed to the medical establishment from within its own institutional structure. He was neither a dissenter from outside nor a radical. His finding, that the modern improvement in health owed little to medical intervention, carries the weight it does because it came from a professor of social medicine using the data medicine itself had generated.
The book appeared in a moment of triumphalist consensus about scientific medicine. The post-war decades had seen antibiotics, mass immunization, the identification of DNA, and the establishment of the National Health Service as a near-sacred British institution. Medical research funding assumed that the recent dramatic improvements in health were the fruit of laboratory science and clinical intervention, and would continue to be so as long as the investment held. Ivan Illich had published Medical Nemesis in 1975 with its charge that medicine did more harm than good. A.L. Cochrane’s Effectiveness and Efficiency had argued from inside clinical practice that medicine had never adequately tested its own procedures. McKeown’s book opened a third front. It accepted that medicine should be evaluated rigorously, declined to treat it as sinister, and then documented, disease by disease and decade by decade, that the historical record did not support the credit medicine had awarded itself. Autopsy studies in 1975-76 had already shown that clinical diagnoses of cause of death were seriously wrong in approximately a quarter of hospital cases. The ground was shifting, and McKeown stood on the shifting ground with his statistics in order.
The book has become a reference point in any serious account of why populations become healthier, cited across epidemiology, public health history, and the terrain-adjacent literature that has argued for the primacy of conditions over interventions. The full summary unpacks what McKeown established about the sequence of causes: that nutrition from approximately 1700, sanitation from the 1870s, and the fall in the birth-rate from 1870 did the work later credited to vaccines and antibiotics; that the Flexner Report of 1910 locked medical education into a case-mix selected by eighteenth-century voluntary hospitals that had systematically excluded the destitute, the infectious, and the chronically ill; that 46% of UK NHS spending in 1970-71 went to acute hospitals that did not care for most sick people; and that the diseases now killing people in developed countries are, like the plagues before them, mostly diseases of how people live rather than problems that will yield to better treatment. In 1796 one-fifth of all deaths in London were ascribed to smallpox. The disease is gone, and medicine will claim it. The children who did not die of it were fed, housed, and sewered first.
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