No one can question the remarkable contribution of US public health to understanding the causes and consequences of illness, disability, and death. However, some commentators question the agenda: the endless pursuit of individual risk factors and the cursory attention to social determinants of disease. We attempt to illustrate some limitations of US public health by focusing on type-2 diabetes (adult-onset non-insulin-dependent diabetes)--an increasingly prevalent but still poorly understood medical condition with devastating complications and implications for quality of life. A more theoretically based multilevel approach to diabetes, outlined for the 21st century, has an almost exclusive downstream curative focus, that ranges from midstream preventive programmes to upstream healthy public policy.