The Health of Populations: Beyond Medicine

Iceland.

Preface

Health is a dynamic state, guaranteed by no one thing. Rather, health derives from myriad aspects of living that comprise the habits and habitats of individuals and populations. Health may be optimized, but not perfected. While it is never too late to strive to recover compromised health, recovery is usually partial rather than complete. Thus, optimal health is founded on ways of living that favor prevention, and prevention rests on minimizing exposure to disease and injury risk factors.

Authorities, national and global, fret about ways to expand biomedical healthcare to avert catastrophe from the escalating global burden of chronic noncommunicable diseases. However, history and current evidence show that biomedical healthcare has contributed comparatively little to the health of populations past and present. Moreover, despite occasional promises of imminent transformational discoveries, there is no realistic prospect of biomedicine succeeding in optimizing the health of current or future populations. Instead of solutions, biomedicine has contributed to the current crisis by way of medical harm to patients, which is now a leading global cause of mortality and morbidity. The evidence, both historical and contemporary, is incontrovertible: Susceptibility to disease and injury is determined more by behavioral and social determinants associated with ways of living than by any other factors. Therefore, the proper role for biomedicine is as an adjunct to risk factor reduction throughout the lifecourse.

In a world characterized by an aging demographic and an unprecedented global burden of disease, individuals can do much to optimize personal health by minimizing individual exposure to risk factors. Ultimately, however, optimizing health requires collective action to transform healthcare by repositioning biomedicine from a dominant to an adjunctive role. Change is required at all levels from the individual to the societal, and from the local to the global. The alternative course, maintenance of the status quo and business as usual, will bring disaster. Continued reliance on biomedical healthcare—with its immense inherent lack of safety, modest efficacy, disappointing effectiveness, and unsustainable cost-effectiveness—will exacerbate the already worsening global epidemic of noncommunicable diseases.

I gratefully acknowledge the many students and colleagues who contributed in diverse ways to the evolution of this book. I am especially grateful to Valmai Gendle, Drífa Harðardóttir, and Janet McQueen for their reading of drafts of the work. I thank the staff of Reykjavík University Library, and especially Unnur Valgeirsdóttir, for the expert bibliographic support they supplied. I also thank the publishers, Elsevier, the production team, and especially Senior Acquisitions Editor, Kristine Jones, for their unwavering encouragement and support. Above all, I am grateful to Drífa for enduring the inordinate hours of my time that this task consumed.

Jack E. James, PhD, Reykjavík, Iceland

Part 1

The Science of Health

Introduction

Medical science and services are misdirected, and society’s investment in health is not well used, because they rest on an erroneous assumption about the basis of health [that has] led to indifference to the external influences and personal behavior which are the predominant determinants.

(Thomas McKeown, 1979, pp. xv-xvi)

Human health varies greatly within and between individuals as well as populations. At any given time, illness afflicts some people and not others, and among those afflicted some are more stricken and others less so. Modern biomedical healthcare has given rise to strong beliefs about the role of biology in explaining variability in health. However, the science of health shows that variation in personal and population health is explained more by psychosocial variables than by biology. In short, biology is not the cause of health and ill-health. Biology is mostly a mediator in causal chains that begin and end in the interactions between people and the environments they inhabit.

Considering the evidence, biomedical dominance of healthcare is difficult to comprehend or to justify. While medical research, innovation, and practice make positive contributions to health, the totality of benefit is comparatively modest. Worse, harm caused by medical interventions, discussed in detail in Part 2, is widespread and of shocking proportions. A profit-driven ethos, which shows no signs of abating, exacerbates much medical harm. Optimizing personal and population health, wellbeing, and quality of life requires the reordering of current healthcare priorities (discussed in Part 3), which need to be directed away from predominantly biomedical preoccupations toward comprehensive recognition that human health is founded on ways of living.

Health and illness are due to innumerable interactive influences that can be thought of collectively as comprising the habits and habitats of human populations. Habitat¹ is familiar in ecology and refers to a given species’ characteristic milieu, inclusive of the physical and social features of that environment. Habits can be considered broadly as comprising the usual or persistent patterns of behavior of individuals and groups. Though rarely used in discussions about human health, the composite phrase habits and habitats is used in the pages that follow to encompass myriad biological, psychological, and social processes that collectively determine human health and wellbeing.

¹ Terms in bold italics are defined in the Glossary.

Chapter 1

The Origins of Health

Abstract

In the centuries preceding the Industrial Revolution of the mid-eighteen century, populations were characterized by short average life expectancy due to high mortality from acute infectious diseases that mostly afflicted the young. Improvements in living conditions associated with economic and social changes transformed population health in countries that were the first to modernize. Mortality fell and average life expectancy increased, characterizing what has come to be referred to as epidemiologic transition. The McKeown thesis, based on detailed studies of infectious disease mortality in England and Wales before and after the Industrial Revolution, holds that the historically recent and unprecedented improvements in health observed in high-income countries were due not to biomedical innovation but to changes in human habits and habitats. In an apparent repetition of that pattern, there is evidence of transformation from high- to low-infection rates and associated increases in life expectancy in progress today in developing countries that are experiencing similar economic and social changes to those that were responsible for earlier epidemiologic transition in high-income countries.

Keywords

Definition of health

The disease perspective

Mind-body problem

Infectious disease

Life expectancy

The McKeown thesis

Tuberculosis

Epidemiologic transition

Psychosocial influences

Noncommunicable diseases

The health of nations is more important than the wealth of nations.

(William James Duran, 1885–1981, American writer, historian, and philosopher)

Contents

1.1 What is Health?   6

1.1.1 Definition of Health: World Health Organization   6

1.2 What Makes Humans Healthy?   8

1.2.1 The McKeown Thesis   9

1.2.2 Tuberculosis   10

1.2.2.1 TB Today   12

1.2.2.2 TB Immunization   13

1.2.2.3 The Key to Successful TB Infection Control Lies in the Centuries-Old Past   15

1.2.3 The Broad Universality of the McKeown Thesis   16

1.3 Historical Causes of Increased Life Expectancy   18

1.3.1 The McKeown Thesis: Criticism, Challenge, and Vindication   21

References   24

It is curious that much informed discussion about health is actually not about health but about disease. The disease perspective, widespread in biomedical science and practice, assumes that health is the default state defined by the absence of disturbances in physiology. Belief in the preeminence of biological explanations of health is part of a continuing yet anachronistic philosophical tradition in biomedicine, traceable to the seventeenth century origins of modern science and the mind-body problem addressed in the philosophy of René Descartes (see Box 1.1). Disinclination to consider nonbiological variables is evident in the healthcare that patients routinely receive, which is dominated by interventions that target biological processes.

Box 1.1

Descartes and Mind-Body Dualism

René Descartes (1596–1650) (Source: http://upload.wikimedia.org/wikipedia/commons/7/73/Frans_Hals_-_Portret_van_René_Descartes.jpg)

Seventeenth-century Europe was marked by intense conflict between the teachings of the Roman Catholic Church on one hand, and the development of reasoning and science on the other. Because the Church regarded humans as spiritual beings controlled by supernatural forces, any systematic study of the body, for example, by means of dissection to learn about anatomy, was perceived as a threat to scripture and was prohibited. René Descartes, French philosopher and mathematician, proposed a solution to the impasse. He argued that mind (soul) and body consist of two distinct substances. The mind, being spiritual and moral, is the province of the Church, while the body, being physical and mechanical, can rightly be subjected to scientific enquiry.

Descartes (Internet Encyclopedia of Philosophy, 1996) did not, as is sometimes claimed, argue the complete separation of mind and body. On the contrary, he argued that the two existed in unity by means of interaction in the brain. Although he was less than precise in describing how such interaction occurred, he did venture to speculate that mind-body interaction was seated in the pineal gland, a small organ resembling a tiny pine cone (hence, its name) located near the center of the brain. The functions of the pineal gland, now known to include regulation of sleep/wake cycles, were unknown to Descartes and his contemporaries. Unlike other brain structures, the pineal gland is a single organ not duplicated in the two hemispheres of the brain. This may have encouraged Descartes to intuit it as a likely candidate for the unique role of mind-body communication. In any event, Descartes’ account provided the foundation for what has come to be known as mind-body dualism. The idea appeased seventeenth-century clerics and paved the way for the future advancement of science, including medical science.

Although Descartes argued that mind and body exist in real distinction from one another and are separable, his speculations about the role of the pineal gland suggest that he may not have intended mind and body to be thought of as being entirely separate. The trouble is that separate is indeed how the person (mind) and body commonly came to be regarded, and biomedicine is a legacy of that traditional way of thinking. Modern biomedical healthcare represents the clearest embodiment of the pretense that physiology is separate from subjective, psychological, and behavioral processes. Biomedicine’s dualistic approach to health is evidenced by its preoccupation with interventions aimed at remedying physiological disturbances in the body without much regard to individual circumstances or wider social influences. Today, mind-body dualism underpins much of the critical discourse about medicinal research and practice. That critique is frequently used in support of a variety of complementary and alternative therapies, including mind-body medicine.

Mind-body practice is claimed to take account of the needs of the whole person by addressing both mind and body. However, mind-body practice is itself open to two major criticisms. First, by arguing the need to take account of both mind and body, mind-body practice can be accused of perpetuating the very thing (i.e., separation of mind and body) that it seeks to denounce. Secondly, whether considered as two separate entities or as a unified whole, mind-body obviously pertains to individuals. Consequently, mind-body practice tends to have an individualistic focus, a feature it shares with biological medicine. Health, however, cannot be appreciated fully by considering the individual alone, even when the individual is treated as a mind-body whole. As argued throughout this book, understanding health requires a population perspective that takes account of the habits and habitats that define ways of living. Only then is it possible to begin to appreciate the biological, psychological, and social complexity of the true determinants of health.

The need to consider patients’ ways of living, their habits and habitats, including health-related behavior (e.g., diet, physical activity, tobacco use, and use of substances such as alcohol), family life, cultural norms, and socioeconomic circumstances, is often acknowledged in biomedical healthcare but generally does not progress much beyond lip service. Reverence for biology is implicit in most contemporary healthcare, and biological exceptionalism (the belief that biological understanding is uniquely important) is sometimes asserted explicitly. When outlining his vision of what is needed to improve the health of current and future populations, the eminent American geneticist Muin Khoury claimed that the most effective way to improve health is to understand normal biology … and its perturbations (Khoury et al., 2012, p. 34). In fact, the contention that biomedical understanding is the foundation for optimizing human health is demonstrably false. The history of medical achievement, discussed in the present chapter, and the contemporary practice of biomedical healthcare, discussed in later chapters, shows that the health of populations has not, is not, and indeed cannot be optimized through advances in biological science alone.

1.1 What is Health?

With its focus on biology and disease, biomedicine’s slender approach to health does not reconcile easily with traditional or contemporary lay perspectives. The word health derives from Old English hælþ, of Germanic origin, perhaps influenced by Old Norse heill, meaning whole, sound, or well (http://dictionary.reference.com/browse/health). Echoes of these ancient origins can be found in brief everyday encounters between people exchanging pleasantries. When asked how they are feeling, the average healthy person typically answers with idioms such as fine, great, pretty good, fit as a fiddle, couldn’t be better, and the like. Though nebulous, these phrases allude to positive states of wellbeing without reference to the absence of ailments or disabilities.

1.1.1 Definition of Health: World Health Organization

A notable exception to the inclination of healthcare authorities to equate human health with the absence of disease is the view promulgated by the peak international authority on health, namely, the World Health Organization (WHO). In 1948, the year of its inception, the WHO proposed that health is:

a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity (p. 100).

In its emphasis on multiple factors (mental and social, as well as physical/biological), the WHO definition of health conflicts with the biomedical view, and this may explain much of the considerable criticism that the definition has received over the years. Most criticism has centered on the definition’s use of the word complete. The concern is that, at best, complete health is experienced by few—and even then, possibly only fleetingly. As one wit opined, if health depended on complete physical, psychological, and social wellbeing, it would be achieved only at the point of simultaneous orgasm (Smith, 2002).

Long before WHO’s inception, the idea of complete or perfect health must have occurred to the Nobel Laureate in Literature (1925), Shaw (1909), who wrote in the preface to The Doctor’s Dilemma, there is no such thing as perfect health [and therefore] nobody is ever really well. This possibly reflects what is generally believed intuitively. Health is a relative state of being that ranges across a continuum that rarely includes perfection. Individually, we are inclined to use comparison as the main method for judging ourselves to be more or less (though rarely completely) healthy. Typically, we judge ourselves to be healthy or not compared to how we have felt in the past, while also comparing ourselves with how healthy we perceive others to be, especially those in our cohort of similar age, occupation, and social group.

Although the WHO definition of health continues to be criticized as unrealistic, such criticism is possibly not merely exaggerated but inaccurate because it is typically made without reference to other key WHO provisions. One particularly relevant provision is the WHO’s (1948) position on health as one of the fundamental human rights of every human being (p. 100). In that context, it is notable that whereas the idealized state of health in the WHO definition comprises complete wellbeing, the right to health is limited to the highest attainable standard. In that respect, the distinction between access to the highest standard of health attainable and the state of complete health mentioned in the definition parallels the distinction that is sometimes made in moral philosophy between means and ends. In the study of ethics, means are actions and ends are goals, with the latter presumed to possess greater intrinsic worth than the former. Immanuel Kant, for example, argued that it is immoral to use a person merely as a means to achieving ends because to be human is an end of greater intrinsic worth than means to ends (Johnson, 2014).

Moreover, just as Kant argued that people should be considered both means and ends (and not merely means), the WHO asserts that health is a resource for everyday life (WHO, 1986, p. 329) and a major resource for social, economic and personal development (p. 330). Therefore, the WHO holds that health is an inherent right (an end) as well as a means for achieving individual and collective ends. Accordingly, if health is a right, and it seems reasonable to consider it as such, it necessarily follows that health involves responsibilities. If so, who bears those responsibilities? As with other fundamental rights, health must, by definition, be a responsibility of collectives (groups, communities, and governments). On the other hand, as with other fundamental rights, it is inconceivable that the collective should bear total responsibility for the health of everyone at all times. Consequently, the right to health also involves individuals assuming responsibility for their own health to the extent that they are able. Thus, health is an idealized state of complete physical, mental, and social wellbeing, and access to the highest attainable standard is a right involving personal and collective responsibilities.

Despite the passage of several decades since the WHO definition of health was ratified as a universal declaration, there is little evidence of its impact on the healthcare that is available to most people. Healthcare remains dominated by biological preoccupations, and most healthcare services consist of what physicians do to people whose biology is deemed to be perturbed. Given that comparatively little healthcare is aimed at protecting health in the healthy, it could be said that health largely is treated differently from other fundamental rights, such as the rights to freedom of movement, freedom of thought, freedom of expression, and freedom of assembly. All such rights are deserving of protection at all times, not only after the fact when a violation has occurred. Health, as a fundamental right, is deserving of similar protections. However, contemporary healthcare is substantially devoid of efforts to protect health, generally being deployed only after health has been compromised. In that regard, contemporary healthcare might more reasonably be referred to as disease care. Furthermore, as discussed in later chapters, the fundamental human right to health is characterized by widespread inequality within and between countries.

In the context of the WHO declaration that health is a fundamental human right to wellbeing that transcends mere absence of disease, the vast, elaborate, and immensely costly structures of contemporary biomedical healthcare are shown to be glaringly deficient. For the benefit of anyone tempted to think of health and biomedicine as essentially synonymous, the WHO definition serves notice of the profound limitations of most contemporary healthcare. Though often criticized and sometimes maligned, the WHO definition of health has remained unchanged for more than six decades. Illuminating past and continuing shortcomings, the WHO definition of health is a beacon to future possibilities. It is a persistent reminder of the radical transformations in healthcare that are needed to address current and looming crises in global health, including continuing widespread inequalities.

1.2 What Makes Humans Healthy?

Guided by the broad framework of health conceived by the WHO, we may venture to ask: what makes humans healthy? It would be natural to think that this question would be a preoccupation of healthcare professionals. However, in the vein suggested above, rather than addressing questions of health, medical dominance of healthcare has resulted in attention being mostly directed at the opposite question, namely, what causes disease? Even if we ignore mental and social wellbeing and focus only on biological health, which the WHO definition implores us not to do, it is perverse to try to account for health solely in terms of what causes illness. Whereas the number and complexity of ways of becoming ill are numerous, the fundamental causes of biological health are comparatively few. Moreover, understanding what makes humans healthy does not require in-depth study. On the contrary, the main causes of health are prosaic. They involve the familiar habits and habitats of everyday human existence.

Despite the priorities of current biomedical healthcare, history shows that the health of populations has never much depended on the arcane knowledge and practices of physicians, hospitals, and biomedical research institutes. In relatively recent historical time, many parts of the world experienced two major transformations in population health and the burden of disease:

• Average life expectancy increased; and

• patterns of mortality (death) and morbidity (sickness and disability) changed from being caused by predominantly acute communicable diseases to chronic noncommunicable diseases.

Understanding those transformations provides major insights into what makes (and keeps) humans healthy.

1.2.1 The McKeown Thesis

Thomas McKeown, British physician and medical historian, has possibly contributed more than anyone to understanding the main determinants of human health. In his book, The Role of Medicine: Dream, Mirage or Nemesis (1979), and other writings (McKeown and Brown, 1955; McKeown et al., 1972, 1975), McKeown reported major historical trends in patterns of population health and disease. His most influential work concerns analyses of historical records for England and Wales covering a period of approximately 200 years from about the mid-eighteenth century. He aimed to explain the rapid growth in population size and especially the dramatic increases in average life expectancy for the period. The overall trend for the latter can be seen in Figure 1.1, which charts a period of about 300 years beginning a little before and ending a little after the period studied by McKeown. Life expectancy at birth in England and Wales, while not always following an unrelentingly smooth trajectory, increased dramatically throughout the nineteenth and twentieth centuries.

Figure 1.1 Life expectancy at birth in England and Wales from 1700 to 2009. (Adapted from Wrigley and Schofield (1981) for the period 1700–1850, Kinsella (1992) for the period 1850–1950, and the Human Mortality Database (2012) for the period 1990–2009.)

During the first decades after the beginning of the Industrial Revolution in the mid-eighteenth century there appears to have been little or no improvement in life expectancy, and possibly a slight decrease. However, by about the beginning of the nineteenth century, life expectancy began to increase to an extent unprecedented in human history. Average life expectancy, it should be said, is not merely a measure of longevity, but also an indicator of the overall health of populations. Obviously, without life there can be no health, and intuitively we sense, correctly, that an increase in the average length of life of a population portends an increase in average health. Because average life expectancy measured at birth is positively correlated with most key indicators of human health, it is often used as a surrogate measurement for comparing the general health of different populations or the same population over time.

The period that McKeown examined coincided with profound change in science and technology. Consequently, it may have been reasonable to assume, as many did, that the increased life expectancy and associated increased population health that were the topics of McKeown’s investigations were due to greater biomedical understanding and improvements in clinical practice. However, McKeown’s analyses showed that biomedicine was not the main cause of the observed improvements in health. Indeed, compared to other factors, the contribution of medical advances to population health was marginal.

For most of the period covered by McKeown’s analyses, illness and death were caused mainly by infectious diseases. McKeown charted the recorded death rates for a wide range of infectious diseases, including tuberculosis (TB), cholera, typhus, typhoid, and a number of childhood infectious diseases, including scarlet fever, diphtheria, and whooping cough. Without exception, deaths from those infections decreased steadily throughout the period. Remarkably, however, McKeown’s analysis showed that most of the decrease in death rate occurred before practical medical interventions had been introduced, and therefore the improvements he observed could not have been due to those initiatives. Of the several diseases studied, the historical records showed that reductions in the rate of death from TB contributed most to the massive gains in health that were achieved.

1.2.2 Tuberculosis

In recent historical time, TB was the main cause of death in England and Wales—and in other comparable countries up to and including the early twentieth century. There was, however, a relentless decline in the incidence of the disease (and in other common infectious diseases) that continued well into the twentieth century. The decline, which is likely to have begun sometime before records began, is depicted in Figure 1.2. Comparing Figures 1.1 and 1.2, it can be seen that the increase in life expectancy (Figure 1.1) mirrored the decrease in TB mortality (Figure 1.2), illustrating the vital contribution of TB mortality to population health. It is important to ask: what brought about the decrease in deaths from TB and the associated increase in life expectancy? The seemingly obvious answer, medicine, cannot be correct because TB had almost disappeared before the advent of relevant medical interventions.

Figure 1.2 Respiratory tuberculosis mortality in England and Wales (1838–2008). (Adapted from McKeown (1979, p. 92) for the period 1838–1900 and the Health Protection Agency (2012) for the period 1913–2008.)

The first real advance in medical understanding of TB came in 1882 when the bacterium responsible for the disease, Mycobacterium tuberculosis (then known as tubercle bacillus from which the abbreviation, TB, derives), was isolated by the German physician Robert Koch (1843–1910). The first public announcement of that breakthrough work was as part of an inspirational lecture Koch gave on 24 March 1882 to the Physiological Society of Berlin (Daniel, 2006). Koch began by recounting the terrifying statistics,

one in seven of all human beings dies from tuberculosis, and [of] the productive middle-age groups, tuberculosis carries away one-third and often more.

(Murray, 2004, p. 1086)

Koch enthralled his audience with a methodical account of his invention of a novel staining method for viewing the bacterium under a microscope, success in isolating the bacterium by growing it in a culture medium, and use of the isolated organism to infect previously healthy laboratory animals with the disease. In due course, his research into TB earned Koch the Nobel Prize in Physiology or Medicine, awarded in 1905. Some consider Koch’s lecture of March 1882 to be the most important in medical history, and one person who was in the audience, Paul Ehrlich, himself a Nobel Laureate in Physiology or Medicine (1908), came to describe it as my single greatest scientific experience (Gradmann, 2006).

In 1890, Koch announced that he had discovered a cure for TB, a development that promised to eclipse even his earlier highly celebrated success. In practice, however, the alleged cure, tuberculin, which he extracted from TB cultures, failed spectacularly (Gradmann, 2006). Notwithstanding his personal lack of success in directly finding a cure, it is instructive to consider the consequences of Koch’s work in the context of the life-saving impact it is sometimes assumed to have had in laying the foundation for subsequent work by others. To begin with, it is important to note that although the toll of death was appalling, as duly noted by Koch at the time of his initial breakthrough discoveries, TB mortality was actually falling rapidly. Figure 1.2 shows that the annual rate of TB deaths had approximately halved from when recording began to when Koch’s work was conducted. Obviously, none of the decline in incidence of TB before that work can be attributed to any life-saving interventions that may have come after.

In fact, more than 60 years passed before the discovery, in 1943, of streptomycin, the first effective antibiotic treatment for TB infection. By the end of that decade, clinical trials confirmed the general efficacy of the new drug, and from about the middle of the century it quickly came into widespread use as a treatment for TB. Nevertheless, more so even than Koch’s original discoveries, the advent of streptomycin came long after the incidence of TB began its relentless decline. McKeown estimated that for the whole of the period from 1838, when TB deaths were first recorded, to 1971, streptomycin probably contributed only about 3% to the total number of lives saved. Even then, the drug was not free of complications, including side effects such as hearing loss, vertigo, and tinnitus. Moreover, rather than delivering cure in all instances, the use of antibiotics in the treatment of TB has in more recent times contributed to the spread of new strains of the disease that are resistant to all currently available treatments. Without diminishing the importance of the lives that were saved, it is obvious that greater importance attaches to the conditions (discussed below) that were responsible for the millions of lives that were spared in which streptomycin and other drugs had no role.

Work on a vaccine for TB had been under way since early in the twentieth century, but human trials involving the use of Bacille Calmette-Guérin (BCG) vaccine (named after French researchers, Albert Calmette and Camille Guérin) did not take place until the 1920s, and attempts at widespread immunization in the form of population vaccination programs did not commence until the 1950s. By that time, almost the entire decline in TB infection that could occur, from the high rates of earlier centuries to the relatively low rates of recent times, had already taken place. The fact is that the transformation of TB from being the leading cause of death to no longer being a major threat happened well before the advent of any effective medical response to the problem. On the simple premise that an effect cannot precede its cause, medical intervention could not have been responsible for the precipitous falls in TB mortality that occurred in many countries over the past 200 years nor the consequential dramatic contributions of decreased TB mortality to increased population life expectancy.

1.2.2.1 TB Today

Despite the comparatively small contribution of TB to current levels of mortality in high-income countries, it continues to be a leading cause of mortality from infectious disease globally, being second only to HIV/AIDS as a cause of death due to infection. Worldwide, there are more than 9 million new cases of TB infection annually and more than 1.5 million deaths (Ottenhoff and Kaufmann, 2012). TB is spread from person to person through the air, and although capable of attacking any part of the body it typically infects the lungs. Neonatal vaccination with BCG has long been thought to provide relatively good protection against childhood manifestations of the disease (Trunz et al., 2006). However, protection is limited, and although estimates vary, the period of cover appears to be in the range of 10-20 years (Aronson et al., 2004; Newton et al., 2008; Sterne et al., 1998). That timeframe coincides with the age-related distribution of the disease in the population, with adults generally showing a higher incidence.

Thus, adult pulmonary TB appears to be the main form of the disease, being responsible for most new diagnoses and contributing most to the global burden of TB-related mortality and morbidity. On the other hand, recent evidence suggests that the incidence of TB infection in childhood may previously have been substantially underestimated due to widespread underreporting of pediatric cases in many countries (Dodd et al., 2014). Notwithstanding possible underreporting, the current global burden of TB infection remains high for all age groups, with by far the largest burden being concentrated in low-income countries. Indeed, this is one aspect of the problem about which there is no disagreement. The countries with the highest rates of TB are those in which poverty and malnutrition are prevalent. Even in countries where population prevalence of the disease is low, the incidence of TB infection is consistently found to be highest among the poor, marginalized, and socially disadvantaged (de Vries et al., 2014).

1.2.2.2 TB Immunization

More than 3 billion people are estimated to have received BCG vaccine, making it the most widely used vaccine in history (Andersen and Doherty, 2005). The first mass BCG vaccinations occurred in countries where population-wide infection rates had already reached relatively low levels (i.e., Britain and some Western European countries). However, BCG vaccine policies and practices vary markedly between countries (Zwerling et al., 2011).¹ That there is variation in policy among countries that have well-established public health systems tends to suggest that the vaccine may have limited efficacy. Were vaccination truly effective, attempts at mass immunization are likely to have been more uniform. In reality, despite policies of population-wide vaccination in some countries, the practice has not been shown to be effective in producing and maintaining low rates of TB infection.

For countries where the risk of infection had already fallen to low levels prior to the adoption of mass vaccination, subsequent additional falls in the incidence of disease cannot alone be taken as evidence of the efficacy of vaccination. In those instances, whatever was responsible for lowering infection risk in the first place could also have been responsible for lowering infection rates still further after mass vaccination was adopted. Some countries, such as those of Western Europe, Britain, Australia, and New Zealand, which have low rates of infection, adopted mass vaccination, whereas other countries, such as the Netherlands and the United States, which also have low infection rates, did not adopt mass vaccination. Rather than attempting to immunize the entire population, some countries, notably the United States, have favored selective vaccination of at risk groups (e.g., healthcare workers and infants living in high-risk settings). Today, mass vaccination is mostly practiced in developing countries² where TB infection risk is high. However, the very fact that infection rates have often remained persistently high in those countries, despite adopting policies of mass vaccination, provides further reason for doubting the efficacy of such programs.

Nevertheless, confidence in modern biomedical innovation and practice appears to run high, judging from the many who evidently believe in the possibility of a fast-track to low population levels of TB for developing countries. That confidence is evidenced by repeated calls from the biomedical community for resources to be committed to the development of new vaccines (e.g., Kaufmann et al., 2010). Conversely, the purported need for such investment merely confirms the limited efficacy of past and present biomedical efforts to confer mass immunity. Had available interventions been effective in achieving near-eradication of TB in those countries where risk of TB infection is low, new vaccines would not be needed. Indeed, it is curious how mass vaccination for TB has been transported from high-income countries to developing countries despite no clear evidence of success in either. Nevertheless, belief in a biomedical solution to TB persists at the highest levels within the biomedical research community (e.g., Sizemore et al., 2012).

The Global Plan to Stop TB, 2006–2015 (Stop TB Partnership, 2006) seeks to eliminate the disease as a global public health problem by 2050 at an estimated cost of USD56 billion. Part of the plan includes the development and implementation of new TB vaccines for mass immunization. While it is a truism that mass immunization with a genuinely effective vaccine could eradicate TB, experience to date does not encourage confidence that any such outcome will be achieved. Decreases in TB mortality and associated increases in life expectancy seen in high-income countries have been real and spectacular. Those transformations, however, occurred despite mass vaccination programs. In an apparent repetition of that pattern, there is evidence of similar transformations from high- to low-infection rates in progress today in countries that are currently experiencing rapid economic development and social change (WHO, 2012), notably, China (Wang et al., 2014).

1.2.2.3 The Key to Successful TB Infection Control Lies in the Centuries-Old Past

Medical interventions for TB, including antibiotic treatment of cases and mass vaccination of populations, have been widespread for more than half a century. Yet, the evidence concerning TB infection rates suggests that, where infection is common, medical intervention has had little success in containing the spread of disease to below epidemic levels, let alone achieving eradication. The current situation, moreover, is exacerbated by the emergence of drug resistance, including multidrug-resistant and extensively drug-resistant strains (Mingote et al., 2015; WHO, 2013), and the more recent and essentially untreatable, totally drug-resistant forms (Rowland, 2012). It is no small irony that medical intervention is known to be the critical causal factor responsible for the increased prevalence of such strains, due largely to the use, overuse, and misuse of antibiotics intended to cure infection.

A recent South African study reported poor long-term outcomes for patients with extensively drug-resistant TB, for whom there are no further options once all existing interventions have been tried and failed (Pietersen et al., 2014). Many of these patients are discharged due to unavailability of long-term treatment facilities, causing the disease to be transmitted to the community. In those circumstances, young children are at highest risk of severe disease and death once infected, but unfortunately until recently the global incidence of multidrug-resistant TB in children had not been quantified. Notably, a recent comprehensive assessment of total global incidence of child cases for all forms of TB yielded estimates 2- to 3-times that of previous official estimates (Jenkins et al., 2014). Almost one million new cases of childhood TB were identified for a single year, including more than 30,000 multidrug-resistant cases, most of which were not officially notified.

In a heartfelt protest to the continued emphasis on biomedical approaches to TB-infection control, Khan and Coker (2014) recently outlined five easy steps that may be taken to hinder TB control. The first step is to continue with current incentives that encourage those working in national TB programs to hide facts and avoid difficult problems. Because stated national goals for infection control are often infused with political capital, healthcare personnel are sometimes reluctant to reveal the true scale of infection rates or intractable problems (e.g., multidrug resistance) for fear of being perceived publicly to have failed. Second, there is the converse step of rushing to address urgent problems (e.g., multidrug resistance), typically by adopting medical or technological solutions of limited efficacy, that divert resources from interventions that will produce better results (e.g., the larger numbers of patients whose infection is of a type that is likely to respond to existing and cheaper antimicrobials). Third, purchasing medical or technological solutions (e.g., for treating multidrug resistance) when the clinical infrastructure (e.g., healthcare centers in remote areas) to disseminate those interventions does not exist. Fourth, encouraging widespread misuse of antimicrobials by allowing them to be dispensed by the unregulated private sector, including private doctors, pharmacies, and local grocery stores in many developing countries. Finally, permitting sudden revisions in level of funding such as may accompany changes in foreign-aid policy that disrupt local infrastructure and impede TB infection control.

To summarize the record of TB infection and control, the relentless fall in the incidence of TB that occurred over long spans of time in widely geographically dispersed economically-developed countries has been largely independent of advances in biomedicine. Biomedical intervention, long the focus of global effort to contain TB, has contributed only marginally to limiting infection rates, while causing substantial harm by contributing to the emergence of new strains of the disease that are resistant to intervention. Despite decades of extensive medical intervention, including mass vaccination, a high prevalence of TB persists in many regions of the world. Moreover, after many years of concerted research and development in TB diagnostics, drugs, and vaccines, the WHO (2014) in its most recent global report on TB estimated that an additional USD2 billion per annum is needed to continue that effort. Results thus far from such research include new drugs currently being tested that show encouraging prospects (WHO, 2014, p. 15), although a vaccine to prevent TB in adults remains elusive (p. 17).

Notwithstanding the substantial global commitment to biomedical approaches to control TB infection, extensive evidence shows that the incidence of TB is closely related to economic development. Consistent with centuries-old trends in countries that were the first to industrialize, present-day developing countries are also experiencing decreases in rates of TB infection. If dramatic benefits of the past and continuing benefits of the present are not attributable to biomedical healthcare, what is responsible? More than 60 years ago, René Dubos, a microbiologist by training, asserted that TB is a social disease (Dubos and Dubos, 1952). He believed that its occurrence is associated with human economic and social conditions, and that its decline in many countries was due to improvements in those conditions. That understanding was confirmed and expanded by McKeown (1979) in his analyses of trends for TB and other infectious-disease mortality in England and Wales during the period in history when Britain industrialized.

1.2.3 The Broad Universality of the McKeown Thesis

The decline in mortality from TB and other major infectious diseases revealed by McKeown’s analyses of records for England and Wales was not a unique episode in history. Essentially the same pattern has been found to have occurred widely throughout Europe (McKeown et al., 1972) and high-income countries elsewhere (McKinlay and McKinlay, 1977). In the United States, total mortality from all causes decreased more than threefold between 1900 (the earliest date for which reliable national data are available) and 1973, with more than 90% of that decrease occurring before 1950 (McKinlay and McKinlay, 1977). In 1900, 11 major infectious diseases (typhoid, smallpox, scarlet fever, measles, whooping cough, diphtheria, influenza, TB, pneumonia, infections of the digestive system, and poliomyelitis) were responsible for about 40% of deaths in the United States. By 1973, the same diseases accounted for just 6% of deaths. While not conducting as extensive analyses as those conducted by McKeown (1979) for England and Wales, McKinlay and McKinlay (1977) arrived at essentially identical conclusions for the United States. Investigating the specific and supposedly effective medical interventions for the 11 major infectious diseases of the period, McKinlay & McKinlay concluded that biomedical healthcare had contributed little to the overall pronounced decrease in mortality. Specifically, they estimated that no more than 3.5% of the total decrease in mortality that occurred in the 70 years from 1900 could be attributed to medical intervention.

The McKinlay and McKinlay (1977) analyses revealed a further intriguing detail concerning annual expenditure on medical care. In the quarter century preceding the mid-1950s, medical expenditure, measured as a percentage of gross national product (GNP), rose from about 3.5 to 4.5% of GNP, but less than 20 years later it had almost doubled to more than 8.5% of GNP. Whatever the reason for the sudden increase in expenditure, it was not rational accounting. As in comparable economies elsewhere, the health of the American population improved greatly during the first half of the twentieth century. However, McKinlay and McKinlay found that, like no other nation, Americans saw fit to massively increase their expenditure on medical care during the third quarter of the century, despite biomedicine actually having contributed little to improvements in the national’s health in the half century before.

Given the consistently observed nexus between the modernization of national economies and decreased incidence of infectious diseases (accompanied by extension of life and improvement in general health), it is moot what might have been the population impact had the medical treatments of the modern era been available two centuries earlier. Would, for example, the decline in TB mortality have been faster and more complete, and the increase in life expectancy greater? The evidence indicates that the pattern of improvement in population health would probably have been little different. While crediting a degree of clinical efficacy to streptomycin, McKeown (1979) attributed little or no benefit to BCG vaccine, citing the Netherlands, which never adopted a national program of BCG vaccination, as having the lowest rate of TB mortality in Europe. The present-day global pattern of TB mortality supports McKeown’s conclusion. Biomedical healthcare was largely irrelevant to the massive saving of life in countries where TB mortality fell sharply in the wake of economic growth and social reforms precipitated by the Industrial Revolution, and the same appears to be true in present-day developing countries that are currently experiencing rapid declines in mortality from TB and other major infectious diseases.

1.3 Historical Causes of Increased Life Expectancy

The importance of the Industrial Revolution in human affairs cannot be overstated. As explained by American economist, Robert Emerson Lucas, Jr, recipient of the Nobel Prize in Economic Sciences (1995), for the first time in history, the living standards of masses of people underwent sustained accelerated growth (Lucas, 2004). Economic prosperity transformed patterns of death and disease, and presaged unprecedented improvements in population health. Immediately after the beginning of the Industrial Revolution, around the mid-eighteenth century, life expectancy changed little for several decades, possibly due to the large influx of people into major population centers that led to overcrowding and worsened living conditions for many. This, however, was followed by a steep and largely unrelenting increase in health throughout the nineteenth and twentieth centuries accompanied by pronounced increases in average life expectancy.

McKeown identified three main causes for the sharp decline in infectious disease and the consequential marked improvements in health and life expectancy that occurred in Britain and Wales. The most important cause, according to McKeown, was improved nutrition. The Industrial Revolution brought with it improved methods of agriculture, including improvements in large-scale food production, storage, and distribution. Increased reliability in the quality and supply of food meant that populations were generally better nourished and less subject to assaults on health from intermittent famine. Consequently, there were major population increases in host resistance to disease leading to lower rates of infection. With a lower infection rate in the population in general, any given individual, whether or not in a state of compromised health, is less exposed to infection and therefore at lower risk than previously of becoming infected. Moreover, improved general health due to better nourishment contributes to an improved rate of survival if infected.

The emphasis McKeown placed on improvements in host (i.e., individual) immunity due to improvements in nutrition resonates with current understanding of infectious disease in general and recent observations concerning the incidence of TB in particular. The worldwide appearance of HIV in the 1980s was followed by increases in the incidence of TB infection. Compromised immune function due to HIV infection dramatically undermines host resistance to infection. Thus, with the spread of HIV, there was a resurgence of TB in countries where its incidence had previously fallen to low levels. TB was found to be concentrated among formerly healthy young adults in whom the disease had all but disappeared, but whose sexual activity during an era of rising HIV infection led to markedly increased susceptibility to TB infection.

Secondly, McKeown identified improvements in population standards of sanitation, especially in relation to the provision of clean water and the disposal of sewage. Those changes were critical for the control of water- and food-borne diseases such as cholera and typhoid. Thirdly, McKeown argued that social innovation made possible by increased affluence contributed to changes in individual behavior and environmental conditions that contributed to improvements in population health. More specifically, declining birth rate accompanied by reduced infant mortality contributed to reduced poverty and increased personal life expectation. Improvements in public education and literacy fostered ongoing improvements in standards of public sanitation and personal hygiene, and large-scale slum clearance and urban renewal projects helped to eradicate sites where infectious disease was most concentrated.

In summary, McKeown found that the main historic causes of increased life expectancy and associated increases in population health were improved nutrition, access to clean water, slum clearance, public sanitation, and personal hygiene. These aspects of life, taken largely for granted in present-day high-income economies, were consequences of the scientific, technological, and social developments that accompanied economic growth precipitated by the Industrial Revolution. Looking only at the surface of things, it is understandable that commentators tended to assume that medical innovation was responsible for the historic improvements in health that characterized the period. McKeown’s work, however, revealed that the main scientific innovations responsible for improvements in health concerned agriculture and engineering whereas developments in biomedicine were largely irrelevant. Importantly, too, the period was characterized by the emergence of progressive social movements that advocated reforms such as slum clearance, public sanitation, general education, and the adoption of personal hygiene (see Box 1.2).

Box 1.2

Soap and the Advent of Personal Hygiene

Box of Amigo del Obrero (Worker's Friend) soap, Museo del Objeto del Objeto, Mexico City. (Source: http://commons.wikimedia.org/wiki/File:MODOAmigo.jpg)

The importance of personal hygiene to health should not be underestimated. According to Curtis (2007), hygiene may be defined as the set of behaviors [used] to avoid infection (p. 660). Curtis believes that most animals exhibit hygiene behavior, which has an ancient evolutionary history. Certainly, personal cleanliness in humans pre-dates recorded history. Water, it may be assumed, has been used throughout the millennia to cleanse the body of obvious signs of dirt, and it is now known that washing with water lowers the risk of infection from microorganisms. Ancient Egyptians, Greeks, and Romans bathed regularly, although cleaning the body with soap appears not to have been common until much later. The first recorded use of soap is from Babylon, where it appears to have been used primarily for cleaning animal skins. Other early soap-like compounds also appear to have been used for cleaning clothes, as hair-styling agents, and as lotions for treating skin diseases.

By the time of the fall of the ancient Roman Empire in about the middle of the first millennium, the habit of bathing all but disappeared in Europe, although it continued elsewhere. For example, in Japan, regular bathing appears to have remained customary throughout the medieval period (fifth to the fifteenth centuries). It was not until the seventeenth century that bathing returned to fashion in Europe. Increasingly, cleanliness came to be regarded as important not only for social distinction but also for health. As bathing increased in popularity, the use of soap for washing the body also became fashionable and demand for soap quickly grew (Geels, 2005). Today, there is extensive scientific evidence for the usefulness of soap. Cleansing the hands is especially effective against the spread of diarrheal organisms that contaminate food and water (Biran et al., 2012).

Handwashing has been particularly well researched in low-income countries, where washing with water alone has been found to reduce diarrhea by about 30% and by about 45% when soap is used (Curtis et al., 2011). Handwashing also reduces neonatal mortality, trachoma (a contagious eye disease), parasitic worm infections, and lower-respiratory-tract infections. In one study, children younger than 5 years in households that received plain soap and handwashing promotion that included information and literature about personal hygiene had a 50% lower incidence of pneumonia than control families that did not receive the intervention (Luby et al., 2005). In an era smitten by technology, it is notable that the most cost-effective single intervention for reducing the global burden of infectious disease may be something as uncomplicated as handwashing with