Open AccessHealth Equity and the Fallacy of Treating Causes of Population Health as if They Sum to 100%
Author(s) -
Nancy Krieger
Publication year - 2017
Publication title -
american journal of public health
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 2.284
H-Index - 264
eISSN - 1541-0048
pISSN - 0090-0036
DOI - 10.2105/ajph.2017.303655
Subject(s) - causation , fallacy , public health , social determinants of health , population , health equity , health care , population health , publicity , equity (law) , actuarial science , medicine , environmental health , law , political science , economics , epistemology , philosophy , nursing
Numerous examples exist in population health of work that erroneously forces the causes of health to sum to 100%. This is surprising. Clear refutations of this error extend back 80 years. Because public health analysis, action, and allocation of resources are ill served by faulty methods, I consider why this error persists. I first review several high-profile examples, including Doll and Peto's 1981 opus on the causes of cancer and its current interpretations; a 2015 high-publicity article in Science claiming that two thirds of cancer is attributable to chance; and the influential Web site "County Health Rankings & Roadmaps: Building a Culture of Health, County by County," whose model sums causes of health to equal 100%: physical environment (10%), social and economic factors (40%), clinical care (20%), and health behaviors (30%). Critical analysis of these works and earlier historical debates reveals that underlying the error of forcing causes of health to sum to 100% is the still dominant but deeply flawed view that causation can be parsed as nature versus nurture. Better approaches exist for tallying risk and monitoring efforts to reach health equity.