COMMENTARIES 7. Kaelber DC, Jha AK, Johnston D, 11. Varon J, Marik PE. Clinical infor- 15. Centers for Disease Control and 19. Pathela P, Harvey K, Blank S, et al. et al. A research agenda for personal mation systems and the electronic med- Prevention. Sexually transmitted diseases The utility of male urethral gram stain for health records (PHRs). J Am Med Inform ical record in the intensive care unit. treatment guidelines, 2006. MMWR informing treatment decisions on the day Assoc. 2008;15(6):729–736. Curr Opin Crit Care. 2002;8(6):616– Recomm Rep. 2006;55(RR-11):1–94. of clinic visit. Paper presented at: 17th 8. Chan KS, Weiner JP. Electronic 624. 16. Centers for Disease Control and Meeting of the International Society for health record-based quality indicators for 12. Shapiro JS, Kannry J, Lipton M, et al. Prevention. Update to CDC’s sexually Sexually Transmitted Disease Research/ ambulatory care: findings from a review Approaches to patient health information transmitted diseases treatment guidelines, 10th International Union against Sexually of the literature. Available at: http:// exchange and their impact on emergency 2006: fluoroquinolones no longer rec- Transmitted Infections World Congress; healthit.ahrq.gov/portal/server.pt/gateway/ medicine. Ann Emerg Med. 2006;48(4): ommended for treatment of gonococcal July 29–August 1, 2007; Seattle, WA. PTARGS_0_3882_217665_0_0_18/ 426–432. infections. MMWR Morb Mortal Wkly 20. Handel S, Schillinger JA, Borrelli J, e-indicator-lit-review.pdf. Accessed January 5, 13. Menke JA, Broner CW, Campbell Rep. 2007;56(14):332–336. et al. STD testing at emergency contra- 2010. DY, et al. Computerized clinical docu- 17. Kuperman GJ, Bobb A, Payne TH, ception visits to local STD clinics. Paper 9. Hillis SD, Owens LM, Marchbanks mentation system in the pediatric inten- et al. Medication-related clinical decision presented at: 2008 National STD Pre- PA, et al. Recurrent chlamydial infections sive care unit. BMC Med Inform Decis support in computerized provider order vention Conference; March 10–13, increase the risks of hospitalization for Mak. 2001;1:3. Available at: http:// entry systems: a review. J Am Med Inform 2008; Chicago, IL. ectopic pregnancy and pelvic inflamma- www.biomedcentral.com/1472-6947/ Assoc. 2007;14(1):29–40. 21. Borrelli J, Paneth-Pollak R, Wright S, tory disease. Am J Obstet Gynecol. 1997; 1/3. Accessed January 5, 2010. 18. Hunt DL, Haynes RB, Hanna SE, et al. The impact of introducing ‘‘express 176(1):103–107. 14. Evans KD, Benham SW, Garrard et al. Effects of computer-based clinical visits’’ for asymptomatic persons seeking 10. Brunham RC, Maclean IW, Binns B, CS. A comparison of handwritten and decision support systems on physician STD services in a busy urban STD clinic et al. Chlamydia trachomatis: its role in computer-assisted prescriptions in an performance and patient outcomes: system, 2005–2006. Paper presented at: tubal infertility. J Infect Dis. 1985;152(6): intensive care unit. Crit Care. 1998;2(2): a systematic review. JAMA. 1998;280(15): 2008 National STD Prevention Confer- 1275–1282. 73–78. 1339–1346. ence; March 10–13, 2008; Chicago, IL. A Framework for Public Health Action: The Health Impact Pyramid A 5-tier pyramid best de- Thomas R. Frieden, MD, MPH scribes the impact of different types of public health inter- ventions and provides a LIFE EXPECTANCY IN DEVEL- and ascending levels with de- of services used by states to allo- framework to improve health. At the base of this pyramid, oped countries has increased creasing impact that represent cate resources for mothers and 6 indicating interventions with from less than 50 years in 1900 primary, secondary, and tertiary children. Infrastructure building 1 6 the greatest potential impact, to nearly 80 years today. The care. Other frameworks more (e.g., monitoring, training, systems are efforts to address socio- greatest improvement occurred in specific to public health have been of care, and information systems) economic determinants of the first half of the 20th century, proposed. Grizzell’s 6-tier inter- is at the bottom of the pyramid, health.Inascendingorder when life expectancy in the United vention pyramid emphasizes pol- followed by population-based ser- are interventions that change States and many parts of Europe icy change, environmental en- vices (e.g., newborn screening, the context to make individ- increased by an average of 20 hancement, and community and immunization, and lead screening) uals’ default decisions healthy, 2 7 years, largely because of univer- neighborhood collaboration. and enabling services (e.g., trans- clinical interventions that re- sal availability of clean water and Hamilton and Bhatti’s 3-dimen- portation, translation, case man- quire limited contact but con- rapid declines in infectious dis- sional population health and agement, and coordination with fer long-term protection, 3 ongoing direct clinical care, ease, as well as broad economic health promotion cube incorpo- Medicaid), with direct health care and health education and growth, rising living standards, rates 9 health determinants (e.g., services at the top. 4 counseling. and improved nutritional status. healthy child development, biol- All of these models, however, Interventions focusing on Smaller gains in the latter half of ogy and genetics, physical envi- focus most of their attention on lower levels of the pyramid the 20th century resulted primar- ronments, working conditions, and various aspects of clinical health tend to be more effective ily from advances in treatment of social support networks) and evi- services and their delivery and, to because they reach broader cardiovascular disease and control dence-based actions to address a lesser extent, health system in- segments of society and re- of its risk factors (i.e., smoking, them (e.g., reorienting health frastructure. Although these are of quire less individual effort. high blood pressure, and high services, creating supportive envi- critical importance, public health Implementing interventions cholesterol).5 ronments, enacting healthy public involves far more than health care. at each of the levels can The traditional depiction of the policy, and strengthening com- achieve the maximum pos- The fundamental composition, 8 sible sustained public health potential impact of health care munity action). The maternal and organization, and operation of benefit. (Am J Public Health. interventions is a four-tier pyra- child health pyramid of health society form the underpinnings of 2010;100:590–595. doi:10. mid, with the bottom level repre- services, developed by the US the determinants of health, yet 2105/AJPH.2009.185652) senting population-wide interven- Health Resources and Services they are often overlooked in the tions that have the greatest impact Administration, consists of 4 levels development frameworks to 590 | Commentaries | Peer Reviewed | Frieden American Journal of Public Health | April 2010, Vol 100, No. 4 COMMENTARIES (e.g., poverty reduction, improved Still, more than 900 million peo- education), often referred to as ple worldwide have no access social determinants of health, that to clean drinking water and about help form the basic foundation of 2.5 billion have no access to ade- a society.11,12 Socioeconomic status quate sanitation.21 As the World is a strong determinant of health, Health Organization’s Commis- both within and across countries.13 sion on Social Determinants Although the exact mechanisms of Health reported, ‘‘Social injus- by which socioeconomic status tice is killing people on a grand exerts its effects are not always scale.’’11(p26) apparent, poverty, low educational attainment, relative deprivation, Changing the Context to and lack of access to sanitation Encourage Healthy Decisions increase exposure to environmen- The second tier of the pyramid tal hazards.14 Educational status is represents interventions that also tightly correlated with car- change the environmental context diovascular risk factors, including to make healthy options the de- smoking.15,16 fault choice, regardless of educa- Although poverty increases ill tion, income, service provision, or FIGURE 1—The health impact pyramid. health within a society, economic other societal factors. The defining development can also increase ill- characteristic of this tier of inter- ness and death from noncommu- vention is that individuals would nicable disease. As living stan- have to expend significant effort describe health system structures. does not see such interventions as dards and life expectancy improve, not to benefit from them. For As a result, existing frameworks falling within the government’s risk for cardiovascular disease example, fluoridated water—which accurately describe neither the appropriate sphere of action. and some cancers increases.17 is difficult to avoid when it is the constituent elements nor the role Interventions at the top tiers are Much of this increase results from public supply—not only improves of public health. designed to help individuals rather modifiable risk factors related to individual health by reducing than entire populations, but they overconsumption of tobacco, un- tooth decay,22 but also provides A FIVE-TIER PYRAMID could theoretically have a large healthy food, and alcohol, with economic benefits by reducing population impact if universally aconcurrentdecreaseinphysical health spending and productivity An alternative conceptual and effectively applied. In practice, activity. Greater wealth can also losses. In countries without