title: Health Equity and the Fallacy of Treating Causes of Population Health as if They Sum to 100.
abstract: 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.
authors.affiliation: Nancy Krieger is with the Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, MA.
authors.forename: Nancy
authors.initials: N
authors.lastname: Krieger
mesh_terms: D000069576:Health Equity; D006801:Humans; D015233:Models, Statistical; D009369:Neoplasms / Q000209:etiology*; D011634:Public Health; D012307:Risk Factors; D064890:Social Determinants of Health