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Objectives. We estimated the number of deaths attributable to social factors in the United States.
Methods. We conducted a MEDLINE search for all English-language articles published between 1980 and 2007 with estimates of the relation between social factors and adult all-cause mortality. We calculated summary relative risk estimates of mortality, and we obtained and used prevalence estimates for each social factor to calculate the population-attributable fraction for each factor. We then calculated the number of deaths attributable to each social factor in the United States in 2000.
Results. Approximately 245000 deaths in the United States in 2000 were attributable to low education, 176000 to racial segregation, 162000 to low social support, 133000 to individual-level poverty, 119000 to income inequality, and 39000 to area-level poverty.
Conclusions. The estimated number of deaths attributable to social factors in the United States is comparable to the number attributed to pathophysiological and behavioral causes. These findings argue for a broader public health conceptualization of the causes of mortality and an expansive policy approach that considers how social factors can be addressed to improve the health of populations. (Am J Public Health. 2011;101:1456-1465. doi:10.2105/AJPH.2010. 300086)
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In 1993, an article provocatively titled ''Actual Causes of Death in the United States'' offered a new conceptualization of cause-of-death classification, one that acknowledged and quantified the contributions of behavior rather than the more typical pathological explanations recorded on death certificates.1 The authors, McGinnis and Foege, found that the most prominent contributor to mortality in 1990 was tobacco (400000 deaths), followed by diet and activity patterns (300000 deaths). A decade later, updated findings by Mokdad et al.2 using data from 2000 showed progress in some areas but the growing contribution of obesogenic behavior (poor diet and physical inactivity). Despite controversy over the methods used to derive the attributable numbers of deaths and the validity of their estimates, especially in the article by Mokdad et al., the findings of both articles have been influential, are frequently cited and debated in the peer-reviewed literature,3-12 and have been cited in discussions of national public health priorities.13
In a 2004 editorial accompanying the article by Mokdad et al., McGinnis and Foege noted that although
it is also important to better capture and apply evidence...