The changing patterns of health in the United States justify both celebration and dismay. We can celebrate declining mortality rates, increased life expectancy, and improvements in diagnostic and therapeutic technologies. But public health was caught by surprise by the return of infectious disease; the gap in health outcomes between rich and poor and between whites and blacks increases; there is a growing discrepancy between what is technically possible and the actual health status; and despite its greater expenditures on health, the United States lags behind the other developed countries in health outcomes. The authors examine four reasons for this: we do not buy more health care, only pay more for it; we receive more health care, but much of it inappropriate, ineffective, or harmful; only some of us get more health care; and we have created a way of life that makes us sick, then spend more to repair the damage. Major failures arise when problems are understood too narrowly. An ecosocial perspective attempts to look at the whole. It rejects as false the dichotomies social/biological, physical/psychological, genetic/environmental, lifestyle/environment, examining their interrelations rather than assigning them relative weights. In addition to looking at average differences among populations, the authors examine patterns of variability in health outcomes.