Tom McKeown’s approach to health care brought public medicine into the modern era. He was a leading exponent of the basis of the new approach - that public medicine must exhibit a comprehensive concern for the medical needs of society. As foundation professor of social medicine at Birmingham University from 1945-1977 he, and a few like-minded contemporaries, could claim to have created the subject. The 32 years that he held the chair included three when he was also pro-vice-chancellor.

In 1940 he married Esme Joan Bryan Widdowson, daughter of a dental surgeon, and they had two children, a son and a daughter.

Tom was born in Portadown, Northern Ireland, the son of William McKeown, a building contractor, and his wife Matilda Duff, daughter of a journalist. He graduated BA in British Columbia and then came to Oxford as a Rhodes scholar. By the age of 25 he had been awarded two doctorates (McGill and Oxford), and he graduated in medicine from Guy’s Hospital medical school in 1942. He was a demonstrator in biochemistry at McGill, and a demonstrator in physiology at Guy’s, before being appointed to the chair at Birmingham. Between 1960 and 1980 he lectured in Canada, the USA and Australia, and in 1976 he was Rock Carling fellow of the Nuffield Provincial Hospitals Trust.

Before the NHS, and indeed up to 1974, ‘public health’ was the professional concern of Medical Officers of Health employed by local government. In practice, their main duties were defined by the environmental protection regulations set out in the Public Health Act of 1936. Tom and his colleagues saw this as a crippling constraint upon any fully integrated medical service for the community as a whole. The approach he advocated and practised was based upon the scientific study of health problems in the community combined with social, administrative, economic, demographic and historical studies. These ideas were reflected in the creation of the specialty of Community Medicine in 1973, which eventually unified the activities of scattered professional groups pursuing different aspects of their subject. Social medicine from then on would have a global rather than a narrow specialized role.

Tom’s early scientific career was based upon the laboratory, in physiology, and his later scientific work upon epidemiology, but his most influential commentaries upon medicine and health owed as much or more to his demographic and historical skills. McKeown argued that the main improvements in health during the last century owed less to consultative and therapeutic medicine than to improvements in the economy, in diet, in public-health engineering, and in the evolution of social and working conditions. Before 1900 doctors probably did more harm than good; between 1900 and 1930, they broke even; but only since 1930, by which time the major health improvements of the present era were established, was it clear that doctors were beginning to win. Although Tom McKeown’s conclusions were not always welcome to doctors, his international reputation in public health circles was among the highest. The medical service had now to be judged almost entirely upon the humanity and quality of care offered to the sick, including the chronic sick, the elderly, the mentally ill and handicapped, and the physically handicapped. These criteria have all been accepted, at least in principle, and it is perhaps difficult now to recall how awful some of these services were, or the low level of priority accorded to them. Here was a philosophy which ultimately required the evaluation of all aspects of medical practice by independent scientists and specialists, and a judgement of worth centred on the most neglected areas. It was not entirely painless.

Tom McKeown wrote two influential books, The modern rise of population, London, Edward Arnold, 1976, and The Role of medicine: dream, mirage or nemesis, Oxford, Blackwell, 1979. In the latter he argued that set against its own curative impotence, medicine must not try to create health but aim to ‘...assist us to come safely into the world and comfortably out of it, and during life to protect the well and care for the sick and disabled.’ The full implications of this simple statement have yet to be realized.

McKeown had an elegant and polished, but formally academic style of writing and oral presentation, which often elicited resistence. But though his audience might resist his ideas, they could find no logical escape and little room for manouevre. It led to a good deal of wishful misrepresentation. Although he received universal academic recognition, there would be no civil honours for a man as forward looking and disturbing as Tom McKeown. Tom’s teachings will, however, be remembered, certainly until such time as they cease to be other than a part of the common understanding of the true nature of medicine.

EG Knox

[The Times, 20 June 1988; The Independent, 21 June 1988; The Guardian, 18 June 1988; Brit.med.J., 1988,297,129;Lancet, 1988,2,58; Guy's Hosp. Gaz., July 1988]