摘要：To identify successes in improving America's health, we identified disease categories that appeared on vital statistics lists of leading causes of death in the US adult population in either 1950 or 2000, and that experienced at least a 50% reduction in age-adjusted death rates from their peak level to their lowest point between 1950 and 2000. Of the 9 cause-of-death categories that achieved this 50% reduction, literature review suggests that 7 clearly required diffusion of new innovations through both public health and medical care channels. Our nation's health success stories are consistent with a triangulation model of innovation plus public health plus medical care, even when the 3 sectors have worked more in parallel than in partnership. There has been much discussion of the relative importance of population-based risk factors versus individual medical care in determining the health outcomes of the US population. 1 , 2 The sibling rivalry between public health and medicine (sometimes referred to as “sick-care” by public health professionals) has often suggested that successes in improving America's health could be easily attributed to one or the other. Joint successes of their combined activity have not been clearly identified. The 20th century was characterized by a major transition in the causes of death, from mostly infectious diseases to more chronic, degenerative diseases. This “epidemiological transition” occurred at roughly midcentury for the United States and much of Europe, with a rapid decline in deaths due to infectious diseases. 3 According to Omran, this epidemiological transition is characterized by a rise in the proportion of deaths first from trauma, then from diabetes, heart disease, and cancer. 4 But what happens after the epidemiological transition? When these trends are reversed for some chronic diseases and cancers but not others, the question arises, why? More recently, there has been a renewed emphasis on social determinants of health. 5 , 6 McGinnis and Foege identified behavioral, social, and environmental determinants as the “actual causes of death in the United States,” while acknowledging that “socioeconomic status and access to medical care are also important contributors, but difficult to quantify.” 7 (p2207) For an earlier generation (1950s through 1970s), physician and demographic historian Thomas McKeown argued against any significant impact of either medical advances or even targeted public health programs, emphasizing instead the “invisible hand” of rising socioeconomic status as the explanation for improvements in population health outcomes. 8 Such root cause analysis perhaps answers the why question, but the cure is not always the inverse of the cause. A very different question is: what has been successful in improving health outcomes in the United States? In other words, addressing root causes may not be the only path to success. We therefore undertook this study to identify successes in improving cause-specific mortality rates in the adult US population, to identify innovations that enabled these successes, and then to identify patterns of success.
