702 October 2001 Family Medicine While most health practitioners view their work as sci- entific and commonsensical, all of us have theories about the world and how it works, ideas that necessar- ily influence our efforts and perceptions in health and health care. Although the dominant medical paradigm remains biological reductionism, a number of alterna- tive theoretical approaches have been introduced. 1 One alternative to the biomedical paradigm, the biopsychosocial model, was proposed by Engel over two decades ago. 2 McWhinney has suggested that we are in the midst of a paradigm shift, as the anomalies of the biomedical model lead to it being supplanted by the biopsychosocial model. 3 Recently, we have seen a number of attempts to modify the biopsychosocial model and find the most promising modification to be that suggested by Farmer, 4 discussed below. In this paper, we applied some of the insights of Farmer and others in an attempt to clarify some con- ceptual issues relevant to the biopsychosocial model. To illustrate this, we used as an example the problem of diabetes in the Marshall Islands, a site where we practice medicine and public health. We examined ques- tions like: How should a problem like diabetes in the Marshall Islands be understood? How can it be ad- dressed? If we use the biopsychosocial paradigm, how does it help our understanding? What is meant by “psy- chosocial” in biopsychosocial? Can the biopsychosocial model take account of large-scale social phenomena? We begin with some background. The Marshall Islands—A Strategic Trust After the Second World War, the United States ad- ministered Micronesia as a trust territory. From 1946 to 1957, the United States tested nuclear weapons in the Marshall Islands, including its largest test, the 15- megaton Bravo blast. This testing resulted in the dis- placement of people, radioactive contamination of is- lands, and direct fallout on Marshallese people. The US Army Kwajalein Atoll/Kwajalein Missile Range (USAKA/KMR), a military base, is housed on Kwajalein Atoll of the Marshall Islands. USAKA/KMR is equipped to track ballistic missiles launched from California. Kwajalein Atoll is also the launch site for the interceptors being tested for the proposed ballistic missile defense system. Depending on the level of On the Biopsychosocial Model: The Example of Political Economic Causes of Diabetes in the Marshall Islands Seiji Yamada, MD, MPH; Neal Palafox, MD, MPH From the Department of Family Practice and Community Health, Univer- sity of Hawaii. Biomedical reductionism, the unwritten theory underlying the practice of medicine, is being supplanted by the biopsychosocial model. The explanatory power of the biopsychosocial model, however, is ham- pered by an inadequate mechanism to account for the social production of disease. We examine diabe- tes in the Marshall Islands to explore a conceptual approach that incorporates ecology, history, and political economy into the biopsychosocial model. The use of the Marshall Islands by the United States as testing grounds for nuclear war has led to ecological destruction, population displacement, and economic dependency. The consequence at the biological level has been an epidemic of weight gain, altered metabolism, and diabetes. A political economic perspective reveals that such outcomes are the result of decisions made by those who do not live with these decisions. Such a perspective points the way for social engagement and political work toward justice and health. (Fam Med 2001;33(9):702-4.)