This story illustrates the traditional emphasis within medicine on diagnosing and treating illness and disability rather than preventing it. Moreover, even when doctors, researchers, and others do focus on preventing illness, they typically look only far enough upstream to see how individual psychological characteristics (such as poor impulse control) or biological characteristics (such as a gene) may make some people more susceptible than others to disease or unhealthy behaviors. In contrast, although sociologists agree that biological and psychological factors affect health, they also recognize that these factors don’t operate in a vacuum. For example, adolescents are most likely to drink alcohol dangerously if their friends and family do so. Similarly, the high rates of diabetes found among contemporary Native Americans partially reflect individual decisions regarding exercise and diet. But they also reflect the effects of living on reservations with ready access to fatty and sugary foods, limited access to fresh fruits and vegetables, and high rates of poverty, which can lead to poor nutrition and in the long run to diabetes. In both cases, to blame unhealthy behavior patterns on individual choices seems simplistic.

As these examples suggest, truly refocusing upstream requires us to look beyond individual behavior or characteristics to what McKinlay refers to as the manufacturers of illness: those groups that promote illness-causing behaviors and social conditions. These groups include alcohol distributors, auto manufacturers that fight against vehicle safety standards, and politicians who vote to subsidize tobacco production.

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One way to refocus upstream is to examine data on the underlying causes of premature deaths—that is, deaths caused by neither old age nor genetic disease. Table 2.2 shows these causes and their prevalence (listed not by disease but by the factors that cause disease). The next section looks at these 10 causes of illness.

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