Policy including Disparities
Policy change is the royal road to progress. Public health has identified policies proven to save lives, and public health evaluation can identify additional policies for further progress.
Health departments must continue to handle traditional public health priorities as well as emerging infectious diseases. They must also increasingly address terrorism detection, preparedness, and response. But it is even more urgent that they adjust to the epidemiological transition from communicable to chronic disease. All too many are asleep at the switch.
Public Health Impact Pyramid
Featured article on health policy: Frieden TR. A Framework for Public Health Action: The Health Impact Pyramid. Am J Public Health 2010;100:590-595.
The public health impact pyramid provides a framework to prioritize action to save and improve lives. At the base are socioeconomic factors such as poverty, education, access to health care, and elimination of health disparities. One level above that are actions that make the default action healthier, such as clean air and clean water laws. Above that are clinical interventions that last years or even a lifetime. Clinical interventions such as treatment of hypertension are one level above that, and counseling and education are at the top. The lower on the pyramid, the larger the impact, but effective programs often work at every level.
Generally, working at the bottom level of the pyramid makes the default decision the healthy decision for people. It's harder for communities to achieve healthy change at this level, but easier for people to stay healthy. The higher up on the pyramid, the lower the impact and the greater the individual effort needed.
Many programs work at every level of the pyramid. Change may take many years, and there may be synergy between working at upper levels and generating the political will to improve the lower levels.
Along the side is surveillance, which is crucially important to improving health. This requires the ongoing, systematic collection, analysis, and interpretation of data with dissemination to those who need to know.
If a program is going well, surveillance data can protect it from attack and preserve it. If a program is going poorly, surveillance is crucial to make that known and lead to progress.
The concept of the pyramid is applicable to a wide range of health problems. Powerpoint slides outlining this in seven different areas are available for download here. I hope you like them!
The Public Health Impact Pyramid applied to a range of health problems
Tuberculosis and its control holds many lessons for broader public health programs. I summarized them in an article* as follows:
TB control is effective when it combines two essential components: a practical, implementable, proven technical package, and political commitment. Political commitment is also essential to implement other interventions that can improve health, including healthier air, water and food, as well as programs to prevent or reduce tobacco smoking, cardiovascular disease, cancer, obesity and other growing public health problems. By implementing evidence-based practices, ensuring operational excellence, using information systems that facilitate accountability and evaluation, and obtaining and maintaining political support, we can address the public health challenges of the twenty-first century.
Health departments must continue to handle traditional public health priorities such as infectious disease prevention and control, as well as emerging infectious diseases. They must also increasingly address terrorism detection, preparedness, and response. But it is even more urgent that they adjust to the epidemiological transition from communicable to chronic disease. All too many public health agencies are asleep at the switch, as I wrote in an article in 2004 that may be one of the most important of any I have written. I note that many of the tools used in the successful control of infectious diseases can also be used for the current non-communicable disease epidemics – the current leading causes of illness, injury, disability and death. These tools include:
- Environmental interventions
- Clinical care
- Outbreak detection, investigation, and control
- Case management and contact tracing
- Health education
For this to occur, there must be more funding for public health – and the willingness to expend political capital.
The biggest difference between control of infectious disease and control of non-communicable diseases is that microbes, unlike the tobacco, alcohol, unhealthy food, and other causes of illness, don't have lobbyists.
What is government's role in protecting health? Does new public health action in chronic disease control represent inappropriate "nanny state" action?
I address this question in an article on the role of government. There are both long-standing and newer aspects of public health action. These fall into three broad categories:
- 1.Promoting free and open information
- 2.Protecting individuals from harm caused by other people or groups
- 3.Taking societal action to protect and promote health.
Government's role in protecting health
These are not "nanny state" actions, these are life-saving actions that support both personal and societal responsibility.
Health disparities can be overcome by innovative, well-designed, and consistently evaluated programs that build viable and sustainable long-term partnerships and inspire political commitment through effective implementation and communication.
Elimination of health disparities isn't just one aspect of public health action, it suffuses all of the public health approach. Disparities by race, ethnicity, age, income, gender, gender identiy, and more persist in the United States and in virtually every country in the world.
In the United States, Black people live shorter lives than White people, and are often affected by negative health trends earlier, and more severely, than others. This has been the case during the Covid pandemic.
There are many things we must do to address disparities. Pushing for fundamental change. Recognizing and reversing racist, sexist, and other pervasive and harmful realities. Expanding empathy.
Public health starts with surveillance. Bill Foege likes to call this, "Knowing the truth." When it comes to disparities, surveillance is one form of bearing witness.
At CDC, I insisted that we start an annual "Surveillance Summary" on disparities. CDC had never done anything like this before, although confronting disparities has been an important part of CDC work since it's creation 75 years ago.
Frieden TR. Foreword: CDC Health Disparities and Inequalities Report - United States, 2011. MMWR Surveill Summ 2011;14;60:1-2.
Announcing this onging report in January of 2011, I noted our "commitment to socioeconomic justice and shared responsibility". Some key findings of that first report:
- Lower income residents report fewer average healthy days. The correlation between poor health and health inequality at the state level holds at all levels of income.
- Both the poor and the wealthy experience the negative health effects of air pollution; racial/ethnic minority groups, who are more likely to live in urban counties, continue to experience a disparately larger impact.
- Large disparities in infant mortality rates persist. Infants born to black women are 1.5 to 3 times more likely to die than infants born to women of other races/ethnicities.
- Men of all race/ethnicities are two to three times more likely to die in motor vehicle crashes than are women, and death rates are twice as high among American Indians/Alaska Natives.
- The suicide rate among American Indians/Alaskan Nativess and non-Hispanic whites is more than twice that of blacks, Asian Pacific Islanders and Hispanics.
- Prescription drug abuse now kills more persons than illicit drugs, a reversal of the situation 15–20 years ago.
- Men are much more likely to die from coronary heart disease, and black men and women are much more likely to die of heart disease and stroke than their white counterparts. Coronary heart disease and stroke are not only leading causes of death in the United States, but also account for the largest proportion of inequality in life expectancy between white and Black people, despite the existence of low-cost, highly effective preventive treatment.
- There also are large racial/ethnic disparities in preventable hospitalizations, with Black people experiencing a rate more than double that of whites.
- Disparities continue to widen as HIV rates increase among black and American Indian/Alaska Native males, as well as MSM, even as rates hold steady or are decreasing in other groups.
- Rates of adolescent pregnancy and childbirth have been falling or holding steady for all racial/ethnic minorities in all age groups. However, disparities persist as birth rates for Hispanic and non-Hispanic black women are 3 and 2.5 times those of whites, respectively.
- Younger people and men are more likely to binge drink and consume more alcohol than older people and women. The prevalence of binge drinking is higher in groups with higher incomes and higher educational levels, although people who binge drink and have lower incomes and less educational attainment levels binge drink more frequently and, when they do binge drink, drink more heavily. American Indian/Native Americans report more binge drinking episodes per month and higher alcohol consumption per episode than other groups.
- Tobacco use is the leading cause of preventable illness and death in the United States. Despite overall declines in cigarette smoking, disparities in smoking rates persist among certain racial/ethnic minority groups, particularly among American Indians/Alaska Natives. Smoking rates decline significantly with increasing income and educational attainment.
Frieden TR. Foreword: CDC health disparities and inequalities report—United States, 2013. MMWR Surveill Summ 2013;62(Suppl 3):1-2.
I note that two fundamental failings of the U.S. health system are lagging health improvement and severe health disparities.
In 1966, Martin Luther King said that “Of all the forms of inequality, injustice in health care is the most shocking and inhumane”. We have made some but not nearly enough progress in reducing the barriers to equitable health care and to health equity. We should work with what he called “the fierce urgency of now” to eliminate this form of inequality wherever and whoever it affects.
Cardiovascular disease is the leading cause of death in the United States. Non-Hispanic Black adults are at least 50% more likely to die of heart disease or stroke before age 75 years than their non-Hispanic white counterparts.
Frieden TR. Foreword: Strategies for reducing health disparities—selected CDC-sponsored interventions, United States, 2014. MMWR Surveill Summ 2014;63(Suppl 1):1-2.
It's not enough to shine a light on injustice; it's important to act to end injustice. In this report, we highlighted programs that empowered communities and reduced health disparities. These included HIV prevention programs, motor vehicle crash prevention programs led by an inspiring coalition of Native American leaders, and, most strikingly, the Vaccines for Children program.
Created in the wake of measles outbreaks which occured in the U.S. in the early 1990s, the Vaccines for Children program (VFC) provides vaccines at no cost to children who might otherwise not be vaccinated because of inability to pay. The program has substantially increased childhood vaccination rates, and constant cycles of program evaluation ensure that VFC continues to have maximum impact.
VFC has eliminated disparities in coverage for many vaccines although some disparities in coverage, while reduced, persist for Hispanic and black children.
We summarised 8 years of effort to improve surveillance at CDC here: Richards CR, Iademarco MF, Atkinson D, Pinner RW, Yoon P, MacKenzie WR, Lee B, Qualters JR, Frieden TR. Advances in public health surveillance and information dissemination at the Centers for Disease Control and Prevention. Public Health Reports. 2017;124(4):1-8.
In addition to bearing witness, public health must take specific actions that reduce health disparities. Examples include the HIV, vaccination, and motor vehicle initiatives mentioned above. When CDC launched a "Winnable Battles" initiative, we identified the disparity-reducing potential of each component. Reducing disparities requires focused work throughout every aspect of public health prorgramming. We outlined that approach here: Frieden TR, Ethier K, Schuchat A. Improving the health of the United States with a “Winnable Battles” initiative.* JAMA. 2017; 17(9).
As one example, reducing teen and unintended pregnancy is an important means to reduce health disparities. Dr. Allan Rosenfield revolutionized the field of reproductive health with one essential insight. As an obstetrician, Allan was acutely aware that women wanted more control over their reproductive future. Until Allan did the studies, this hadn't been well documented, and well-intentioned but ill-advised programs wrote about "population control" and mistakenly feared an imminent Malthusian catastrophe.
The fact is that teen and unintended pregnancy often results in the intergenerational transmission of poverty. By fighting for reproductive rights, public health can help empower women to take control of their health.
In this tradition, we focused on reducing teen pregnancy as a key goal of the Winnable Battles initiative. With partners from around the country, the ambitious goals were met, and teen pregnancies and births were reduced dramatically. I believe that our efforts are part of what resulted in a more rapid decline in teen births starting around 2010.
Teen births have been falling steadily, with faster declines after 2010
Hypertension prevention and control is a good example of a program that can improve health generally and also greatly reduce health inequalities. It can't be emphasized strongly enough that hypertension is the leading single health condition contributing to the difference in life expectancy between Black and White Americans.
It's good to fight for incremental progress, but it's important to recognize that the persistent health disparities in the U.S. are, literally, killing people. That's why it's also important to address more basic causes of health inequality – the lower parts of the health impact pyramid
I addressed this issue in an article in 1994 that has a special meaning for me. Frieden TR. Tuberculosis control and social change. Am J Pub Health 1994;84:172-173.
I argued that in addition to specfic actions to better diagnose and treat tuberculosis, we needed to "improve the social and economic environment that provides the substrate for the tuberculosis epidemic in the United States and abroad."
Why does this article have special meaning for me? Because the then-director of the World Health Organization's tuberculosis control programme read it, liked it, and decided to recruit me and send me to India as a result of this. What followed were the five hardest but most meaningful years of my professional life, supporting India as it scaled up tuberculosis control services to save millions of lives.
At the CDC, with the leadership of John Auerbach, we developed the "HI-5" inititiave – measures that could improve health in 5 years or less. The focus on the bottom two levels of the health impact pyramid, and include 14 proven ways to improve health, ranging from better physical activity programs in schools to better public transportation, ealy childhood education, earned income tax credits, and home improvement loans and grants.
There's a faction of public health that believes that health care is too controversial, expensive, and ineffective to merit much attention. This perspective isn't as off-base as it might seem. Most health improvement doesn't come from health care, but rather from either broad social changes (education, income) or classic public health measures (clean water and clean air, fluoridation, smoke-free public places, taxation of tobacco, alcohol, and other unhealthy products, etc.).
But starting in the middle of the 20th Century, health care got effective enough to have the potential of doing more good than harm. An important article by Ford, of the CDC, showed that the decrease in heart disease and stroke was caused, in equal measure, by public health and clinical improvements.
As New York City health commissioner, I tried to improve health care, with a focus on the poorest and sickest communities: the South Bronx, Harlem, and Central Brooklyn. Among a range of programs we launched, we created an electronic health record initiative for medical practices in these areas.
We asked a simple question: what is the best way to save lives with health care. Remarkably, that hadn't been answered in the medical literature, so we had to do the analysis. The result is striking: blood pressure control, by a long shot.
Blood pressure control can save more lives than any other clinical intervention
However, health care isn't structured to maximize health.
Along with Farzad Mostashari, I published a thought-piece Health care as if health mattered. * (JAMA 2008; 299:950-952.) We noted that:
The most serious shortcoming of health policy in the use is that the nation's health system is not designed to maximize health. Individuals in the United States receive only about half the recommended medical services.1 Only 43% of individuals with diagnosed diabetes,2 37% with hypertension,3 and 25% with hypercholesterolemia4 have adequate control of their disease; furthermore, less than 20% of smokers who try to quit receive assistance from their physicians, and only 2% are prescribed pharmacotherapy.5 Lack of effective primary health care is a public health problem that results in avoidable blindness, amputations, strokes, heart attacks, and premature death. Nearly 9 of 10 Americans with uncontrolled diabetes, hypertension, and hypercholesterolemia already have private or public health insurance.6
We noted that electronic health records (EHRs) could greatly improve care, but only when combined with payment reform that changed the incentives. We concluded: "unless the clinicians involved receive meaningful additional payment for delivering better health to their patients, the health information technology and practice redesign cannot be replicated, sustained, or expanded."
This remains an unfulfilled promise and potential of health reform in the United States.
In a seminal article, Dr. Colin McCord noted that men in Harlem had a shorter life expectancy than men in Bangladesh. I am fortunate that Dr. McCord has been one of my mentors, and he noted that one of the surprising and unexplained findings of his study was the high rate of death from chronic liver disease.
From McCord and Freeman, N Engl J Med 1990; 322:173-177
Frieden TR, Ozick L, Henning KJ, et al. Chronic liver disease in Central Harlem: the role of alcohol and viral hepatitis. Hepatology 1999;29:883-888.
Studying this was complicated but with a superb research assistant, Mattie Dickerson, we completed a detailed case-control study with a clear conclusion: synergistic liver toxicity from alcohol and viral hepatitis. Either viral hepatitis or heavy alcohol use is bad for your liver, but both of them together are particularly bad. Years later, this was one additional reason CDC recommended routine testing for hepatitis C. As I said at the time we made this recommendation, "You may not remember all that you did in the 1960s, but your liver does." Avoiding alcohol is particularly important for people with hepatitis B or C infections.
The combination of alcohol use and viral hepatitis is particularly dangerous
Geoffrey Rose wrote about alcohol harms in his classic book, Preventive Medicine.
“Of all the threats to human health, it is alcohol which causes the widest range of injury. It shortens life, being variously held responsible for between 1% and 10% of all adult deaths in industrialized countries. It shrinks the brain and impairs the intellect. It causes failure of the liver, heart and peripheral nerves. It contributes to depression, violence and the breakup of personal and social life. It has been blamed for a quarter of all deaths on the road – divided about equally among drunk drivers, drunk pedestrians and innocent victims.”
The epidemic of opiate overdose reflects a combination of medical error, underlying socioeconomic stress, and failed public policy.
In the United States, treatment of both pain and addiction is insufficient. At CDC, we created guidelines for opiate treatment to help address this problem, and along with Dr. Deborah Houry, I explained these guidelines. Simply put, opiates are the most dangerous drug class of all, and should be used sparingly if at all outside of severe acute pain and palliation.
Led by Nora Volkow and along with others, we called for a massive expansion of treatment of opiate addiction. Although far from perfect, treatment of addiction should ALWAYS be offered. It is unethical to do otherwise. Denying treatment for addiction to a patient in an emergency department, prison, or homeless shelter is unethical, just as it would be to deny treatment for diabetes, hypertension, or cancer.
Along with Andrew Kolodny, I outlined steps* the Federal government can take to confront the opioid epidemic.
Ultimately, addressing drug and alcohol use will require broad social and economic action as well as specific measured to reduce harm.
Reprints. Articles marked with * are available by request (all others are open source and available through the links). To request a reprint: