I got an A in geometry. I never cleared calculus, but I know my shapes. Below is my favorite shape, the Health Impact Pyramid, developed by Dr. Thomas Frieden, the director of the Centers for Disease Control and Prevention. Let me tell you why it’s awesome.
This pyramid illustrates the effectiveness of different types of public health work, but the concept can be transferred to pretty much any issue.
Education and counseling–working on one person at a time–are at the top of the pyramid. Just below that is ongoing medical care from doctors. Again, working on one person at a time.
The middle layer of the pyramid are one-time or infrequent interventions that have a lasting impact, like immunizations or smoking cessation programs, that are still delivered to one person at a time, though they may be delivered population-wide.
The fourth layer of the pyramid is what Dr. Frieden calls “changing the context to make individuals’ default decisions healthy,” by which he means public policies like clean water and safe roads. You don’t have to depend on people making the right choice to drink clean water versus contaminated water, or choosing safe roads over dangerous roads. There are only clean water and safe roads to choose from, because it’s the law. The default is the best choice, chosen by millions of people at a time.
The bottom layer of the pyramid addresses socioeconomic factors like poverty, education and homelessness. Again, affecting millions of people at a time.
The downward arrow on the left shows that the impact of the work is highest at the base of the pyramid, while their effectiveness is reduced as you climb towards the top.
The upward arrow on the right shows the effort required from an individual, with the least effort required from an individual at the bottom, where impact is the greatest, and the most effort required from an individual where the effectiveness is lowest.
Nutshell: The greatest improvements in people’s lives come from addressing the socioeconomic status of poor people and from enacting public policies that promote good health. The lower on the pyramid you work, the more people you’ll help, no matter what issue you work on.
Of course, work at each level is important, but the most powerful effects are found at the base.
The focus of many organizations is almost the inverse of this pyramid, where a lot of time and money is spent trying to teach people how to improve their own lives, through education about drug abuse, or media campaigns to encourage walking, but these are actually the least effective ways to change behavior and help lots of people at a time.
That doesn’t mean those efforts are wasted. But to be most effective, we need to move towards the root causes of problems found at the base of this pyramid. That’s the kind of advocacy I teach and do. When I worked on forest protection, I didn’t want to depend on the personality or whims of each individual forest manager, I wanted to change the law so it applied everywhere uniformly, so each forest manager only had one action to choose, and that was to protect forests.
Think about what level of the pyramid you work on. Does that feel right to you? Again, work at all layers is important, but some work has a bigger impact. Got questions or comments? I want to hear them so please post them below.
And if you haven’t already downloaded these free guides, you can get them at the links below. If you can think of other tools that would be helpful, please let me know.
One of the biggest challenges organizations have is the campaign planning process. To help serve them, I’ve created a guide of the 11 essential points that I use with organizations, as well as with my grad students at Johns Hopkins. In it you’ll find the critical elements your campaign must have. Use this as an easy reference guide for staff, volunteers & trainers.
- The 10 steps of power mapping
- The questions to ask and where to find answers
- Easy reference guide for staff, volunteers & trainers
- What coalitions do
- Who to recruit
- How to pick the best coalition name
- Attracting diverse coalition partners10
- Leadership & structure of coalitions