No one can question the remarkable contribution of US public health to unde
rstanding the causes and consequences of illness, disability, and death. Ho
wever, some commentators question the agenda: the endless pursuit of indivi
dual risk factors and the cursory attention to social determinants of disea
se. We attempt to illustrate some limitations of US public health by focusi
ng on type-2 diabetes (adult-onset non-insulin-dependent diabetes)-an incre
asingly prevalent but still poorly understood medical condition with devast
ating complications and implications for quality of life. A more theoretica
lly based multilevel approach to diabetes, outlined for the 21st century, h
as an almost exclusive downstream curative focus, that ranges from midstrea
m preventive programmes to upstream healthy public policy.