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Special Article
Shattuck Lecture

The Future of Public Health

ThomasR. Frieden, M.D., M.P.H.
From the Centers for Disease Control and
Prevention, Atlanta. Address reprint requests to Dr. Frieden at the Centers for
Disease Control and Prevention, 1600 Clifton Rd., Atlanta, GA 30333, or at tfrieden@
cdc.gov.
N Engl J Med 2015;373:1748-54.
DOI: 10.1056/NEJMsa1511248
Copyright 2015 Massachusetts Medical Society.

he field of public health aims to improve the health of as many

people as possible as rapidly as possible. Since 1900, the average life span
in the United States has increased by more than 30 years; 25 years of this
gain have been attributed to public health advances.1,2 Globally, life expectancy
doubled during the 20th century,3 largely as a result of reductions in child mortality attributable to expanded immunization coverage, clean water, sanitation, and
other child-survival programs.4
Public health focuses on denominators what proportion of all people who
can benefit from an intervention actually benefit. Maximizing health requires
contributions from many sectors of society, including broad social, economic,
environmental, transportation, and other policies in which government plays key
roles; involvement of civil society; innovation by the public and private sectors; and
health care and public health action. Although there has sometimes been distrust
and disrespect between the health care and public health fields,5 they are inevitably and increasingly interdependent; maximizing potential health gains is a defining challenge for both fields.

Buil ding a Publ ic He a lth Py r a mid

To maximize impact, public health works at five levels (Fig.1). At the first level
the base of the pyramid are socioeconomic factors such as income, education, housing, and race. Although these factors are not diseases, both public
health efforts and health care can have some effect on them for example,
through health insurance coverage that reduces poverty or through prevention of
teen pregnancy to reduce the perpetuation of poverty. Immediately above the socioeconomic factors are traditional public health interventions that change the
context to make default decisions the healthy choices (e.g., by providing clean
drinking water). At the next level are long-lasting protective interventions, such as
immunizations, that require only intermittent action by the health care system.
Next are clinical interventions requiring long-term, daily care, such as bloodpressure control. The last level includes counseling and education, such as exhorting people to eat healthy food and be physically active. Each level is important, but
interventions at the pyramids base generally improve health for more people, at
lower unit cost, than those at the top.6
To increase the impact of clinical care on population health, improvements in
the third and fourth levels need to be implemented more effectively. Blood-pressure control, which can save more lives than any other clinical intervention,7 is
successful in only about half of Americans; nearly 90% of patients with uncontrolled hypertension have both health insurance and a regular source of care, and
more than 80% have multiple contacts with the health system each year.8
To maximize health overall, both communicable and noncommunicable dis1748

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Shat tuck Lecture

ease threats need to be addressed in the United

States and globally. There are important connections between infectious and noninfectious diseases: most cases of cervical cancer and many
cases of liver cancer can now be prevented
through vaccination; diabetes, obesity, and tobacco and alcohol use increase risks of both
cancer and infections. U.S. and global health are
also inextricably connected, as outbreaks of Ebola
virus disease and the Middle East respiratory
syndrome (MERS) and the spread of drug resistance make clear. Nevertheless, it is useful to
give separate consideration to ways of addressing infectious and noninfectious conditions.

Increasing population
impact
Counseling
and education
Clinical interventions

Long-lasting protective interventions

Changing the context to make individuals default

decisions healthy

Infec t ious Dise a se s

in the Uni ted S tate s
Despite progress over the past century, the
United States continues to face substantial infectious disease challenges. Human immunodeficiency virus (HIV) infection, hepatitis C virus
infection, drug-resistant bacteria, health care
associated infections, and preventable influenza
and pneumonia continue to kill more than
100,000 people in the United States each year.9-11
The increase in drug resistance, higher prevalence of risk factors such as diabetes and obesity,
aging of the population, and greater complexity
of medical interventions make infectious-disease
control increasingly important and challenging.
Addressing these challenges requires a combination of technological advances, more effective
clinical and administrative systems, and political
commitment to invest in prevention and control.
From a public health perspective, an effective
clinical system has five essential characteristics:
consistency, patient-centeredness, team-based
care, registry-based information systems, and
continuous improvement in treatments and delivery. These core features can help clinical systems address infectious-disease threats through
standardization of care, interventions that increase patient adherence, team-based approaches
to care (including hospital stewardship programs),12 rigorous monitoring of outcomes, and
continuous improvement in detection, treatment,
and prevention. Standardization and team-based
care can increase vaccination rates and reduce
prescription of unnecessary or overly broadspectrum antibiotics. Registry-based approaches
have the potential to increase the proportion of

Increasing individual
effort needed

Socioeconomic factors

Figure 1. The Health Impact Pyramid.

Public health focuses on denominators what proportion of all people who
can benefit from an intervention actually benefit. Improvements at the base
of the pyramid generally improve health for more people, at lower unit cost,
than those at the top. Adapted with permission from Frieden.6

patients with HIV infection who are effectively

treated from the current rate of 40% or less in the
United States.13 Coordination among health care
facilities and public health departments can substantially reduce the spread of drug resistance.14
Technological advances present new opportunities for infectious-disease control. These include large-scale, real-time whole-genome sequencing, which can improve identification of
organisms, resistance, and infection clusters and
elucidate the effects of the microbiome on health.
New technologies complement and enhance but
do not replace core epidemiologic functions.

Infec t ious Dise a se s a round

the Wor l d
Recent decades have seen substantial progress
in addressing some infectious diseases globally.
Rates of death from the acquired immunodeficiency syndrome (AIDS),15 tuberculosis,16 and
malaria17 have decreased substantially. Tropical
diseases such as filariasis are being controlled.18
Polio and guinea worm disease are nearly eradicated.19,20 Vaccination programs prevent more
than 2 million deaths each year among children

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under 5 years of age, although at least another

1.5 million deaths could be averted if current
programs were expanded and new vaccines developed.21
The Ebola epidemic that began in West Africa
in 2014 revealed once again how a weak link in
disease detection and control anywhere can be a
vulnerability everywhere. In theory, control of
Ebola is simple. Programs must find, isolate, and
safely care for infected people, track contacts,
and safely bury patients who die. The challenge
in West Africa has been to undertake these tasks
in communities with no electricity or running
water, no Internet or cell-phone coverage, large
segments of society that are nonliterate and
trust neither the government nor modern medicine, and a near complete lack of core public
health infrastructure.
The Ebola outbreak offers three essential lessons. First, every country must have the core
public health functionality to identify a threat
when it emerges, stop it promptly, and prevent it
wherever possible. The goal of the Global Health
Security Agenda is to strengthen every countrys
capacity, including trained epidemiologists, highquality laboratories, timely and accurate diseasesurveillance systems, and rapid response teams.22,23
Second, when national capacity is overwhelmed, the world must be able to move immediately and decisively. Epidemics are global problems. The World Health Organization (WHO) and
its Global Outbreak Alert and Response Network
need to strengthen global response capacity in
epidemiology, laboratory science, clinical care,
logistics, anthropology, and other disciplines
essential for disease control. The responses in
individual countries can be quicker, more efficient,
and more cost-effective than a global effort but
only if systems in daily use can be rapidly scaled
up in emergencies.
Third, the lack of effective infection prevention and control in hospitals and other health
care facilities is a key vulnerability. Because Ebola
infections, MERS, and the severe acute respiratory syndrome (SARS) usually result in severe
illness or death within weeks after exposure, the
presence and spread of these infections are readily apparent. But tuberculosis,24,25 diseases caused
by drug-resistant organisms,26 Clostridium difficile
infection,27 measles,28 and many other conditions
are routinely spread in health care facilities. Every
country needs a strong system to support, coordinate, and monitor infection control in health
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facilities. Such facilities need full-time staff

dedicated to monitoring and improving infection control, and facility leadership needs to
fully support these staff.

Chronic Dise a se s in
the Uni ted S tate s
Tobacco use is still the leading underlying cause
of death in the United States and worldwide.
Smoking prevalence in the United States is declining, albeit slowly. Smoking-cessation counseling and treatment are effective clinical interventions, but public health interventions, including
raising tobacco taxes, expanding smoke-free
public places, running hard-hitting antitobacco
advertising campaigns, reducing images of smoking in movies and television, and increasing the
purchase age to 21 years, can reduce smoking
rates much more. In its first 3 years, the Tips
from Former Smokers advertising campaign
from the Centers for Disease Control and Prevention helped at least 300,000 smokers quit and
saved at least 50,000 lives, at a cost of less than
$500 per smoker who quit, less than $400 per
year of life saved, and less than $3,000 per life
saved.29 Regulation of the toxicity and addictiveness of combustible tobacco holds promise for
reducing the harms of tobacco but faces certain
opposition from the tobacco industry.
Improved cardiovascular care, particularly better blood-pressure control, can save far more
lives than any other clinical intervention but will
require substantial improvement at the fourth
level of the pyramid. Better implementation of
the ABCS daily aspirin use for people at
high risk, blood-pressure control, cholesterol management, and smoking cessation could save
100,000 lives yearly in the United States if rates
of clinical service utilization increase to those
achieved by high-performing systems.7 Every
10% increase in the number of people effectively
treated for hypertension would lead to prevention of an additional 14,000 deaths a greater
impact than that of any other intervention studied.7 Nationally, just over half of adults with hypertension have it under control, up from slightly over 40% 15 years ago.30,31 But health systems
such as Kaiser Permanente Northern California32
and communities such as MinneapolisSt. Paul33
have increased control rates to 70 to 80%.
Some of the highest-performing U.S. health
systems Geisinger,34 North Shore,35 and oth-

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Shat tuck Lecture

ers examined data from electronic health records and found that nearly a third of people
with multiple elevated readings were never told
that they had high blood pressure, much less
had it treated. Investigators identified and treated patients with elevated blood-pressure readings and created automated reminders to find
and treat patients who would not otherwise be
included in the denominator for clinical quality
measures.36
High sodium intake is a leading contributor
to hypertension, and Americans consume an
average of 3500 mg of sodium per day, far more
than recommended. Reducing average sodium
intake by a third could save up to half a million
lives and nearly $100 billion in health care costs
over the next 10 years.37,38 Because the sodium
content of most processed and restaurant foods
puts reducing intake beyond personal or clinical
reach,39 action is needed at the societal level,
such as working with food manufacturers and
restaurants to steadily reduce sodium content.
In the United Kingdom, industry initially resisted government calls to voluntarily reduce
sodium content but then reduced sodium levels
in many food categories by 14 to 36% in 2 to
3years achieving a 20% reduction in bread
between 2001 and 2011 and a 57% reduction in
breakfast cereals between 2004 and 2011.40 Average British sodium intake fell by 15% between
2003 and 2011, and there was a substantial reduction in average blood pressure, a 40% drop
in the number of deaths from heart attacks, and
a 42% decrease in deaths from stroke, with reduced sodium intake estimated to account for a
quarter to a third of the mortality reduction.41
Although the rapid increases seen in obesity
since the 1970s appear to have leveled off, obesity and overweight continue to be serious problems in the United States.42 Increasing physical
activity and improving nutrition are keys to obesity prevention and control, and policies that
change the environment to make healthful eating and regular physical activity easier, safer, and
more attractive are likely to be most effective.43

Chronic Dise a se s a round

the Wor l d
Even in low-income countries, chronic diseases
and injuries now kill twice as many people as
infectious diseases, and rates are higher than
those in high-income countries. The only excep-

tion is sub-Saharan Africa, although chronic

diseases are increasing there as well. Healthier
populations will increase economic stability and
growth, and effective collaboration to implement programs that address these diseases can
provide important lessons on how to tackle the
leading causes of preventable disability and premature death.
Tobacco use kills more than 6 million people
per year more deaths than HIV, tuberculosis,
and malaria combined, and nearly 80% of these
deaths occur in low- and middle-income countries.44 Without urgent action, tobacco use will
kill more than 1 billion people in this century.
Bloomberg Philanthropies, joined by the Bill and
Melinda Gates Foundation and supporting WHO
and individual countries, have expanded the
WHO-recommended MPOWER strategy in recent
years (Table1). These efforts are expected to
prevent more than 7 million deaths in the 41
countries that fully implemented at least one
MPOWER policy between 2007 and 2010, and
that impact is expected to increase dramatically
in the future.45 Nevertheless, much more must
be done to reduce tobacco use.
Hypertension is the only condition that kills
more people globally than tobacco use more
than 9 million per year.46 Blood pressure does
not necessarily increase with age if sodium intake, physical activity, and other factors remain
in the healthy range.47 However, even with effective community-wide interventions, there will be
substantial need for treatment of hypertension.
Currently, only about one in seven people with
hypertension has it under control. Improved
functioning at the fourth level of the pyramid,
including through standardized protocols that
simplify availability, delivery, and use of core
blood-pressure medications and allow tasks to
be delegated to nursing and nonmedical staff,
could save a million or more lives worldwide
each year; a reduction of sodium intake in conjunction with treatment could save even more.46
In much of the world, motor vehicle crashes
are now the leading cause of death among people 15 to 29 years of age. Public health interventions at the lower levels of the pyramid are effective, inexpensive, and highly cost-effective. Such
interventions include lowering allowable blood
alcohol levels for drivers and implementing random traffic stops to reduce drunk driving; increasing the use of seat belts, child restraints,
and helmets; promoting increased taxation of

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Table 1. MPOWER Strategy for Tobacco Control.*

Policy Strategy

Target

Monitor tobacco use and

prevention policies

Obtain data from surveys of nationally representative samples of adults and young people, conducted within the past 5 yr and collected at least every 5 yr

Protect people from tobacco

smoke

Ensure that all public places (health facilities, schools and universities, government facilities, indoor offices and workplaces, restaurants, bars and cafes, public transport) are
completely smoke-free or that at least 90% of the population is covered by complete
subnational (local or regional) smoke-free legislation

Offer help to quit tobacco

use

Establish national toll-free quit line and full coverage of both nicotine-replacement ther
apy and at least some cessation services provided by health clinics or other primary
care facilities, hospitals, health professionals, or community organizations

Warn about the dangers of

tobacco

Ensure that warning labels cover at least 50% of the front and back of individual pack
ages of tobacco products and appear on any outside packaging and labeling used in
retail sale that include pictures or pictograms and that such labels include specific
health warnings; describe specific harmful effects of tobacco use on health; are large,
clear, visible, and legible; rotate periodically; and are written in the principal language
or languages of the country
Promote advertising campaigns to be aired on television, radio, or both as part of a comprehensive tobacco-control program and including research on target audiences;
pretesting of campaign messages and communications materials; purchase of radio
and TV airtime, print and billboard advertising, and other placement using a thorough media-planning process that effectively and efficiently reaches the target audience; working with journalists to gain publicity or news coverage for the campaign;
and evaluations of campaign implementation effectiveness and impact

Enforce bans on tobacco

advertising, promotion,
and sponsorship

Promote a ban on all forms of direct and indirect advertising of tobacco products, including advertising on national television and radio, in local magazines and newspapers,
on billboards and outdoor advertising, and at the point of sale; on free distribution of
tobacco products in the mail or through other means; on promotional discounts; on
nontobacco goods and services identified with tobacco brand names (brand stretching); on brand names of nontobacco products used for tobacco products (brand
sharing); on product placement in television or films; and ban sponsorship by the
tobacco industry

Raise taxes on tobacco

products

Revise tax laws so that more than 75% of the retail price of tobacco products is tax

* Adapted from the World Health Organization.44

alcohol; and reducing and enforcing speed limits. Better-engineered roads and vehicles also
increase safety and reduce crash injuries and
deaths. Policies require effective enforcement,
which is lacking in many parts of the world.

The Rol e of G ov er nmen t

tecting adulterated food, prohibiting alcoholimpaired driving, and protecting workers and
the public from second-hand smoke. Legal and
policy changes in this area often both reflect
and accelerate changes in social norms. The
third is to implement societal interventions
when individuals cannot efficiently or effectively
protect their own health through such policies
as vaccination mandates, clean air regulations,
water fluoridation, micronutrient fortification of
food, and elimination of lead in paint and gasoline interventions that have all greatly improved the health of Americans.1,49

A responsive government can maintain that people are responsible for their own health while
also taking public health action that changes
default choices to make it easier for people to
stay healthy.48 Key public health actions do one
of three things, all of which are now well accepted but were initially controversial. The first
The F u t ur e
is to promote free and open information such
as truth-in-advertising laws and nutrition-facts In the future, clinical medicine could see costs
panels. The second is to protect people from increase without substantial improvement in
harm caused by others for example, by de- health outcomes.50 Alternatively, new delivery
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Shat tuck Lecture

models and technology could substantially increase healthy life expectancy. The public health
field, for its part, may not be able to keep pace
with changing risks and increased opposition to
core public health actions that promote healthy
living or it could expand its past successes to
further reduce tobacco and alcohol use, control
persistent infectious diseases, increase physical
activity, improve nutrition, and reduce harms
from injuries and other environmental risks.
By working more closely together, clinical
medicine and public health can help each other
improve health maximally and emphasize
societys responsibility to promote both healthy
environments and consistent, high-quality care.
Public health organizations can publicize information on health outcomes and risks that clarifies the need for, or achievement of, substantial
progress. Clinical experts can identify and validate preventable harms and effective interventions to protect patients.
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The involvement of many parts of society,

including government agencies, health organizations, nongovernmental organizations, clinicians,
the private sector, and communities, is increasingly important for success. Everyone benefits
when people are healthier.
Accountability for outcomes is essential
public healths obsession with denominators can
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Presented as the 125th Shattuck Lecture at the annual meeting of the Massachusetts Medical Society, Boston, May 1, 2015.
Disclosure forms provided by the author are available with the
full text of this article at NEJM.org.
I thank the Massachusetts Medical Society for the honor of
presenting the 2015 Shattuck Lecture; Richard Garfield, R.N.,
Ph.D., Sherri Berger, M.S.P.H., Michael Iademarco, M.D., M.P.H.,
and Debra Houry, M.D., M.P.H., for critical review of the manuscript; and Kathryn Foti and Drew Blakeman for additional research and assistance in the preparation of the manuscript.

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The New England Journal of Medicine

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