lundi 26 novembre 2018

Calendrier de l'avent des lectures médicales : Thomas McKeown. #2

McKeown est l'imparfait contradicteur de Ivan Illich puisque sous le prétexte de raconter ce qui a conduit aux formidables succès épidémiologiques de l'époque moderne, il fait la part de ce qui revient à la médecine et de ce qui revient au reste, les effets concomitants et déterminants de l'amélioration d l'hygiène publique et privée, de l'amélioration de l'alimentation et de la sécurité alimentaire et de l'organisation des services de santé et de protection sociale universalisés et solvabilisés. Il contredit à la fois la thèse d'Illich et celle des triomphalistes de la médecine pure et dure.

McKeown Thomas. (1979) The rôle of Medicine: Dream, Mirage or Nemesis. Oxford: Basil Blackwell.

Le livre est accessible en ligne (et en anglais ; cela fait partie des innombrables livres non traduits en français...)  : ICI.

Une critique favorable du livre en anglais : 
In a book that is often grouped with Effectiveness and Efficiency (Cochrane) and Limits to Medicine(Illich), Dr McKeown attempts to calculate the role of medicine in the improvement in health seen over the preceding centuries. He also points out the current problems with medicine (in the 1970s, anyway) and makes suggestions for the future of medical practice, education and research.  Fortunately, many of his suggestions have been realised, but unfortunately, the contribution of medicine to the continuing improvement in health remains overestimated.
Pour la suite : LA.

Et des critiques défavorables, dont celle-ci de 2002 : ICI.

Dont voici la conclusion : 
A large and growing body of research suggesting that broad social conditions must be addressed in order to effect meaningful and long-term improvements in the health of populations has validated the underlying premise of McKeown's inquiries. This research challenges public health professionals to view targeted interventions and social change, not as dichotomous or opposing choices, but rather as essential complements to each other, and to find ways to integrate technical preventive and curative measures with more broad-based efforts to improve all of the conditions in which people live. These concepts, which lie at the heart of the McKeown thesis, account in large measure for its continuing resonance in the field of public health. McKeown's work, empirically flawed though it may have been, placed before a wide audience a set of practical and ethical challenges with which policymakers in the United States and internationally will continue to grapple in the coming decades.

Et encore celle-ci (LA) de 2008 dont voici le résumé : 

Thomas McKeown was right in his primary claim that changing environments, rather than improved medical care, were responsible for much of the long wave of historical mortality decline in the UK since 1700. He was, however, apparently unaware that the beginning of the decline in infant and early-childhood mortality lagged behind that for adults by a few decades, and therefore that its causes might have been fundamentally different. In fact, current evidence indicates that his suggestion, that ‘improved nutrition’ was the underlying factor in the overall decline, now appears to have been essentially correct for the much earlier decline in adult mortality, especially due to tuberculosis. However, the current consensus is that changing reproductive patterns, occasioned by a changing socio-cultural and perhaps legal environment, related to child labor laws, lay behind the much later and very rapid decline in early-life mortality. One must therefore give McKeown great credit for his grasp of both the importance of nutrition, and of the environment, as basic determinants of health.

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