Public Health Pyramid Revised: More “Realistic” Public Health Interventions

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June 9, 2014

Public Health Pyramid Revised: More “Realistic” Public Health Interventions

By Joie Meissner, ND

The basic concept of a public health pyramid supposes that there are societal interventions which have relative value as far as their health promoting effects and for which efforts directed at improvements in these interventions will have a greater or lesser ability to improve the health of society as a whole. The pyramid shape is a very simple way to symbolize the concept that different interventions have relative value as greater versus lesser contribution to public health. The Health Impact Pyramid proposed by Thomas R. Frieden, MD, MPH is a prime example of this concept and provides much guidance for directing the efforts of those involved in public health research, policy and action. [1] (See figure 2 below) Though a pyramid shape can well represent the hierarchical importance that any given intervention may have, a more complex shape, one similar to a mobile with double ended arrows used to symbolize how improvements in one area of society can reinforce improvements in other areas and vice versa more aptly crystalize the precariousness and interconnectedness that actually exists between different aspects of societal interventions as they impact public health. The interconnected shapes with double arrow linkages symbol represents a model of public health intervention that would provide more “bang for the buck” because less effort would be required to achieve the same degree of positive health outcomes via the snowballing effects that improvements in one area would have in other areas of society. Because we are living in a global society where what one group of individuals does affects the health of humanity as a whole, the mobile symbol is the preferred shape to symbolize the interconnectedness and mutuality of the state of health of the various aspects of the world community. The relative size of each of the interconnected shapes and their relative distance from the center of the figure would symbolize the relative importance of that intervention to the grand scheme of public health in its totality. Thus, on general principles, the Interconnected Shapes model is superior to Frieden’s level 5 in his pyramid model.

Even though the interconnected shapes model is an advancement over the previous pyramid model, these two figures may still contain similar specific prioritization in the relative importance of particular aspects of societal health interventions as far as their relative contribution to public health. To determine the size and relationships of each of the symbolic shapes to each other one must first establish the main constituents of and their relative contribution to public health as well as the hierarchy of interdependencies between the constituent elements. Special attention should be given to the base or centerpiece.

It can also be argued that the ideal public health symbol would change based on the socioeconomic system of the society whose health it is designed to address. The Frieden Health Impact Pyramid model sets socioeconomic factors as a foundational area of the greatest effect on public health and proceeds to recommend such things as improving economic opportunities and infrastructure in the world’s urban slums.[2] This is a laudable proposal which if implemented would likely substantially improve public health.[3] However, as our public health professors have told us, public health proposals are frequently made and as frequently ignored by the agencies and bodies charged with providing the funds or enacting the requisite regulations and thus such proposals however well researched they may be, fall on deaf ears.[4] Therefore, the content of an effective public health symbol must be compatible with the power structure in which it operates if it is to be of any practical value.

Even though Frieden is correct in representing that interventions that address economic inequality would likely improve public health substantially, history reveals that lasting change is in large part, accomplished via a preponderance of small incremental evolutions rather than abrupt revolutions and under the current economic hegemony interventions targeting social especially economic inequality are seen as revolutionary and against the “wisdom” of the “free”-market. Hence, an effective public health model would at least initially need to be supportable via the main components of its capitalistic milieu.[5] Public health interventions that profit big business may seem like an oxymoron but in fact, these would require the least effort on the part of activist/social change mechanisms that are of limited resources. Such interventions could potentially provide large positive impacts on public health. At minimum, the content of an effective public health symbol cannot deviate from the socioeconomic and political system to the degree that its implementation would run extensively contrary to its prime directive; the profit motive. For example, a public health intervention that relies on the hegemonic elite driven power structure to implement redistribution of wealth to the indigent majority without equal or greater financial compensation to said hegemonic minority is doomed to failure even if it is well researched and documented by government funded research. Power does not acquiesce to health, ethics or research. The evidence for this is all around us, as we watch our fellows and our children expire in the polluted air we breathe and the heavy metals in the fish we have to be afraid to eat.[6]^,[7],[8],[9]

In the current socioeconomic system, public health risks are most commonly addressed albeit often inadequately, only after negative health outcomes related to various industrial activities have been sledgehammered by the press. Obviously, it is more efficient to prevent than to clean up after the fact; but public health interventions that address prevention are difficult to implement. A prime example of this is the history of smoking and public health prevention. The first Surgeon General’s report on the health hazards of smoking came out in 1964 yet public health policies have failed to successfully combat the smoking menace as evidenced by the fact that cigarette smoking is still the leading cause of preventable death and according to the CDC website everyday roughly a thousand persons younger than 18 years of age become new daily cigarette smokers.Four decades after the Surgeon General warned us that smoking increases the risk of potentially fatal disease, tobacco advertising and promotion expenditures were close to $23 million a day in 2011. ^[10],[11] Because there are strong economic interests that have lobbied hard to prevent restriction of tobacco industry advertising, the U.S. spends billions of dollars per year on smoking related healthcare costs and lost productivity.¹⁰ Because health prevention runs contrary to the profit motive, laws that limit introduction of new chemical into the environment, that require long term independent testing prior to use of potentially toxic or carcinogenic products, environmental chemicals or bioengineered food products are inadequate or non-existent. Implementation of large scale preventative health interventions such as these threaten industry profits. Industrial corporations fund universities and spends millions lobbying congress. Thus, since public health prevention is a threat to the system that funds it, even though the socioeconomic base of Frieden’s Health Impact Pyramid model would be an extremely beneficial area to direct efforts towards, there is no infrastructure support and in fact quite the opposite.

If not Frieden’s socioeconomic base then what should be at the center of the new public health pyramid, the new Interconnected Shapes Health Advancement model? The centerpiece of a health advancement model is the area that has the most influence over the greatest number of surrounding areas and that area is psychosocialspiritual factors. This is because the main area of the society that can impact public health policy which is not premised on the profit motive but rather on a motive premised on the public good is psychosocialspiritual in nature and because psychosocialspiritual factors are needed to overcome culture wide anomie. Culture wide anomie is thought to be playing an important role in maintaining the public apathy and inaction fostered by the public’s observation that the policies they want are overridden by those higher up on the economic scale.

Due to rapid technological and economic change combined with the breakdown of social structures that connect individuals, inform social norms and standards there has been a traumatic society wide breakdown of social conscience, the effects of which we are not yet fully aware.[12] The moral context is being lost to the rise of social fragmentation and isolation and the supplantation of family and the community by ubiquitously advertised vacuously competitive symbols of higher socioeconomic status acquisition. Though the society may not yet be able to consciously voice its moral and psychic distress, such moral deregulation is evident in a casual glance at the public’s seeming apathy in regards to the numerous media headlines on numerous threats to public health and to the health and wholeness of humanity. Scandals are viewed as in a manner consistent with passing media entertainment. It is evident that there is very little in the way of major sustained public action. What has been missed by the previous public health pyramid models is that society wide anomie has sent shock waves of disabling social distress into the various agencies that could intervene in the current public health crises, a crisis in large part, generated by unregulated commercial will run riot.

Because a primary impediment to the implementation of effective public health policies may be psychosocialspiritual in nature and because socioeconomic interventions are unsupportable under the current infrastructure therefore, the centerpiece of the Interconnected Shapes Health Advancement model must be a psychosocialspiritual entity and not a socioeconomic one. Additional support for this centerpiece is that effective psychosocialspiritual interventions have a cascading ability to positively impact interventions in numerous other areas. It has been overwhelmingly demonstrated across cultures that those on the bottom of the socioeconomic ladder have worse health just due to their inferior social status alone, independent of their access to or utilization of health care services, genetic or other environmental health risks.[13] In fact, there is a dose-response relationship between inferior social status and increased drug addiction, crime, teen pregnancy as well as declining levels of health.¹³ The reasons for this are hypothesized to relate to the stress evoked by the framework set up by social status hierarchies in which a great deal of insecurity results for status competition, the precariousness of one’s position in social ranking and the stress and depression generated by the sense of inferiority resulting from perceived or actual lowly status in such a hierarchy. Social inequity generates higher levels of stress/anxiety, anger/hostility and depression and it is well known that stress dysregulates immune function and is an independent risk factor for many common diseases.¹³ High depression scores and lack of social support predict myocardial infarction and all-cause mortality.[14] Anxiety (p<.0000001) and depression (p=.00003) as well as anger and hostility (p<.0000001) have been shown to be significantly related to coronary artery disease.[15] There is ample evidence that increased levels of stress, anxiety and depression lead to an increase in negative health behaviors such as smoking and overeating and others.

Hence, either via the direct effects of stress and other negative emotions or via the indirect effects of these emotions on health behaviors, public health is profoundly affected by the negative psychoemotional states generated by virtue of one’s position in a social status hierarchy. Moreover, the added psychosocial distress generated by culture-wide anomie impairs the individual’s ability to engage in the public health activism required to make the most substantive improvements in the health of the society. Therefore, the existence of an entrenched social status hierarchy combined with the deprivation of conscience wrought by the social trauma generated by the current state of anomie demands a psychosocialspiritual foundation as the centerpiece of a modern health advancement model.

Furthermore, the current climate of social hierarchy in which worth is measured by the attainment of material possessions, materially based features and attributes is a direct attack to self-worth. The value of the individual to themselves and their social group is based on factors that are not intrinsic to the self. This leads to profound devaluation of the authentic self. Self-commodification is used as a means of external locus of control by infrastructure forces. Self-commodification has become the norm since advertising psychologist, Edward Bernays, developed ingenious method for motiving the public to levels of spending behavior never before seen in the history of advertising. Self-commodification, self-obsession and the desire for instant gratification promoted by advertising along with the increasing level of social isolation, often combined with emotional trauma to spawn an epidemic of people that are suffering from psychosocial stresses that bankrupt their sense of self-esteem. As a result, the numbers of persons with substance and behavioral addictions are on the rise. Lack of value for the self is profoundly wounding. So much so that attempts at normalization of affect (restoration of sense of wellbeing) become overriding motives that reside on a more foundational level than the self-actualizing need to help one’s community by engaging in political activism, social change, or other humanitarian activities that could improve the public health. Moreover, even when those who are wounded by self-commodification and social isolation engage in activism their efforts are often hard to sustain and may even become self-destructive at times.

When the wounds of self-commodification, social isolation and psychological trauma have been sufficiently addressed, the individual tends to experience decreased stress and may be able to recover from addictive behaviors that once took control of their lives. Many see spiritual healing as premised on turning the light of consciousness beyond the wounded self-commodified self. Once a greater level psychosocialspiritual health has been attained there may be increased freedom to from the imprisonment of self-focus fostered by commercialism. Once the more essential psychosocialspiritual self-esteem needs have been addressed, the functional level described by Maslow’s Hierarchy of Needs as self-actualizing, can be engaged and activities that address the public good can occupy a greater degree of space in the psyches of the individuals in society. When more fundamental needs have been addressed by psychosocialspiritual interventions the society can undergo the radical shift from an economy based on self-commodification to a more sustainable “wisdom economy” based on self-actualization. The former impasses imposed by hegemonic economic interests will be more easily dislodged by revitalization of conscience and research-based public health policies more freely implemented.⁵

Interventions that target psychosocialspiritual development have a snowballing effect and they do not ostensibly oppose powerful economic interests. Experts assert that the common experience that the emotionally spiritually wounded in turn wound their young and to a greater or lesser degree inflict wounds on the social sphere around them.[16] Thus, a greater number of people with higher degrees of global functioning become available as planetary problem solvers who will in turn be available to support the psychosocialspiritual needs of others in order to become planetary healers themselves. It is also likely that interventions that target this sphere can be designed to create an atmosphere that supports higher levels of self-care which can oppose the tendency to neglect the health in favor of social status acquisition as promoted by the social status hierarchy. That is one way in which such interventions might result in an upwardly spiraling effect on public health.

The beauty of psychosocialspiritual health interventions as the centerpiece of the Interconnected Shapes Health Advancementmodel over the socioeconomic base of the old public health pyramid model is that it does not ostensibly threaten the economic power structure. Not only will it not threaten the economic infrastructure the social trends that such interventions are likely to spawn will inevitably be viewed by the ruling interests as yet another cultural fad to exploit as a further avenue of profit. This was seen in the “hippie movement” which was co-opted by corporate interests that sold the stolen images of counterculture life to the masses.[17] Paradoxically, those interventions that set the stage for greater self-actualization may lead to the incremental unraveling of the exploitative economic system that they inconspicuously occupy.[18]

The counterargument to a psychosocial spiritual centerpiece is that subcultures that predicate themselves on this model already exist and these groups have not been involved in public policy movements; they have not taken a stand on any public issue. Yet, it is because the social status hierarchy placed on the members of these subculture groups is low compared with that of the larger culture that these groups are significantly challenged in these sorts of public policy areas. In addition, many popular groups such as 12-step groups predicate themselves on having but one purpose, the health of their membership. The lowly status incurred by these groups based on their non-materially based identity is interpreted by the larger culture as an identity of material status failure. The low status imposed on them by the larger culture represents a marked obstacle in any area that requires their being publically acknowledged for what the larger culture deems as their weakness not as their strength. For example, the members of 12-step recovery movement are often marginalized in the media as the “broken-toys” of society. Thus, the argument that sub/countercultures that pursue psychosocialspiritual health have not had a substantive impact on public health must be met with the fact that these subcultures are subjugated to the social trauma and psychosocialspiritual dysfunction of the larger society. It is not that these groups would be at the center of achievement of action for the public good but rather, that the model would facilitate their inclusion in the aggregate of society that has become available to work on meeting its own public health needs.

The island of psychosocialspiritual healing is as much a myth as the no smoking section of an airplane or the no-urination area of a public swimming pool. Psychosocialspiritual healing is infectious and a culture that imparts worth to the individual based on his or her intrinsic characteristics rather than on material attributes is a vector of healing. Society has yet to invest in this sort of a public health project in any consistent way. In fact, we have invested in public health projects that convey messages antithetical to this. The “War on Drugs” is a flagrant example of a public health intervention that was premised on self-negating rather than self-affirming messages. In truth, there can be no such “war” on inanimate objects; there is only a war on people. Therefore this failed policy has accomplished nothing to facilitate the self-esteem of those afflicted with substance abuse and/or chemical dependency issues and it has done nothing to put a dent in drug use. A war on people is the antithesis of the proposed public health model, a model whose centerpiece is based on improving the psychosocialspiritual health of people not declaring war on them.

Figure 2    Adaptation of The Health Impact Pyramid created by Thomas R. Frieden, MD, MPH “A Framework for Public Health Action: The Health Impact Pyramid” Am J Public Health 2010  [19]

With some exceptions and alterations, the other shapes and shape titles in the above Interconnected Shapes Health Advancement Mobile have been selected for reasons that parallel those given by Frieden, originator of the older public health pyramid model. (See figures 1 above) The content, specific prioritization and relative importance of each of the shapes in the new interconnected shapes model are in many respects analogous to that of Frieden’s model with the following exceptions. (See figure 2 above) Because it is more descriptive of interventions targeting socioeconomic inequality, the pyramid level or tier that Frieden termed “Socioeconomic Factors” isnewly renamed “Socioeconomic Equality” in the interconnected shapes model. Even though it has been acknowledged that interventions in this area provide proportionately very large pay-offs in terms of improving public health, because interventions designed to target this area tend to be met with inaction this shape has been given second billing in the new model. The main rationale for the deviation from Frieden’s model is that because they run counter to the hegemonic power structure, interventions that attempt to alter the social status hierarchy are viewed as “revolutionary” and are thus met with inaction. Although, as Frieden quoting the World Health Organization aptly points out, socioeconomic factors namely social injustice are “… killing people on a grand scale.”, the harangue of research that sledgehammers this point falls on deaf ears. [20] Thus, efforts should still be ongoing in this area with a somewhat relatively greater effort placed where the results have more real versus theoretical impact.

Because “Changing the Context to Make Individuals’ Default Decisions Healthy” the second tier of Frieden’s model, is subsumed by the models centerpiece, “Psychosocialspiritual Interventions”, this phrase has been omitted in the new model. Since psychosocialspiritual health fuels the engines of social change that are responsible for the materialization of campaigns, laws and policies that improve health directly and indirectly via lessening social equality, interventions that target both these area dovetail and propel interventions targeting the psychosocialspiritual basis for health, the centerpiece of the mobile. Thus, “Socioeconomic Equality” and the ”Societal Health Policies that Improve Health” (a new category) would be equally sized shapes that branch out from the larger central shape and these would be endowed with double- arrow connectivity as these areas are mutually reinforcing.

Branching out ever further from the center would be shapes of decreasing size and increasing distance from the center signifying first “Prevention”, analogous to Frieden’s third tier “Long-Lasting Protective Interventions”, second “Clinical Care” analogous to his fourth tier, “Clinical Interventions”, and third “Docere” (Doctor as Teacher), analogous to his fifth tier entitled “Counseling and Education”. ^[21] The rationale for these designation is essentially the same as that given by Frieden; namely that interventions directed at the former areas have greater impact to the masses and greater ease of compliance for the individual than interventions directed at the latter area.

This newly proposed public health model, the Interconnect Shapes Health Advancement Mobile thus, builds on the work of its predecessors, while at the same time overcomes a major stumbling block of the older socioeconomic-based pyramid model which threatens the economic hegemony. The new model gives top priority to our essential humanity and capacity for transcendence over the cultural freeze of anomie and self-commodification. The model also reflects the interconnectedness of societal policies that improve health and socioeconomic equality with the main centerpiece. The sun shape conveys the snowballing nature of the interaction between all the elements of the model.

The public health strategies that could be employed using this new interconnected shapes model are theoretically unlimited. As societal evolution takes place, the efforts will take on new directions to accommodate the changing needs of the transforming culture.Interventions addressing the psychosocialspiritual needs of society could for instance, be targeted to increase spiritual grounding, promote psychosocial equality and raise self-esteem. For example, “public health commercials” could be designed that glorify the “richness” garnered by a rich spiritual life. Such “public health ads” could depict meditation and communing with nature or spending quality time with friends, family and community as viable alternatives to mindless consumerism. Large chain stores could be offered tax breaks for displaying sensationalized public health posters that depict 80 plus year old men and women as highly attractive, electric members of society. Such posters could be prominently positioned in supermarket checkout lines adjacent to fashion magazines or tabloids displaying thin, young swimsuit models. Public service announcements on nationwide television could portray persons of all shapes, colors and sizes as being highly valued for the content of their character rather than the content of their wallets or the make and model of their automobile. Such public health campaigns could be labeled as the “War on Low-Self-esteem and Self-objectification”. Campaigns such as these could play a role in freeing up cognitive space to fuel the cultural transformation, a transformation that could remedy the catatonic, disengagement and loss of moral context that have blossomed in the wake of the anomie that is sweeping through this culture. The seeds of these sorts of interventions could eventually lay the groundwork for improvements in people’s availability as self-secure, public health problem solvers who can overcome the obstacles that currently stymie the efforts of public health researchers and others who attempt to design public health pyramids to improve public health.

Works Cited

[1] Frieden, Thomas R., 2010. ‘A Framework for Public Health Action: The Health Impact Pyramid.” Am J Public Health. 100(4);590-595

[2] Frieden, Thomas R., 2010. ‘A Framework for Public Health Action: The Health Impact Pyramid.” Am J Public Health. 100(4);590-595

[3] “Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, Switzerland.” World Health Organization; 2008. at:http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf. Web 6 Feb, 2011.

[4] Oberg, Erika. Public Health Lecture, Bastyr University Winter 2011

[5] Castañeda, Gonzalo. “Alternative routes of political change: Elites fracture or social mobilization, economic incentives or cultural thresholds.” 2010. Journal of Socio-Economics, In Press. Web 6 Feb 2011

[6] Gurjar, B.R. et al. 2010.”Human health risks in megacities due to air pollution.” Atmospheric Environment. 44(36); 4606-4613

[7] Sharon L Harlan, Sharon L, Ruddell, Darren M. 2011.”Climate change and health in cities: impacts of heat and air pollution and potential co-benefits from mitigation and adaptation.” Current Opinion in Environmental Sustainability, In Press, Web 1 Feb 2011

[8] Ashmore, M.R., Dimitroulopoulou, C.2009. “Personal exposure of children to air pollution.” Atmospheric Environment. 43(1) 128-141

[9] L.E. Fleming, L.E.et al. 2006. Oceans and human health: Emerging public health risks in the marine environment. Marine Pollution Bulletin. 53(10-12);545-56

[10] “The Role of the Media in Promoting and Reducing Tobacco Use”. Bethesda, MD: National Cancer Institute; 2008. Tobacco control monograph 19. NIH Publication. 07-6242. Web 6 Feb 2011

[11] “Smoking and Tobacco Use”-The Centers for Disease Control and Prevention http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/ Web 14 July 2013

[12] B. Giesen. Social Trauma. International Encyclopedia of the Social & Behavioral Sciences, 2004, Pages 14473-14476

[13] Richard Wilkinson and Kate Pickett. 2011. “Inequality: the enemy between us? How Inequality Hurts Societies.” Thursday, January 27, 2011 at 11:00 AM EST. New global research on equality, inequality, and the happiness of nations. It’s an American issue. Web 6 Feb 2011

[14] Welin Cet al. J. 2000. “Personality and CAD”. Intern Med. 2000;227:629

[15] Friedman HS, Booth-Kweley S. 1987. Am Psychol 1987;42:539

[16] Bradshaw, John. 1988. Healing the Shame that Binds You. Health Communications INC. Houston Texas

[17] Meissner, J. “Subculture; dressing for ideals”. Unpublished work 1996

[18] Murtaza, Niaz. “Pursuing self-interest or self-actualization? From capitalism to a steady-state, wisdom economy.” 2011. Ecological Economics. 70 (4);577-584

[19] Frieden, Thomas R., 2010. ‘A Framework for Public Health Action: The Health Impact Pyramid.” Am J Public Health. 100(4);590-595

[20] Frieden, Thomas R., 2010. ‘A Framework for Public Health Action: The Health Impact Pyramid.” Am J Public Health. 100(4);590-595

[21] Frieden, Thomas R., 2010. ‘A Framework for Public Health Action: The Health Impact Pyramid.” Am J Public Health. 100(4);590-595