It is not necessary (although desirable) to know everything about the natural history of a disease to initiate preventive measures. Often times, removal or elimination of a single known essential cause may be sufficient to prevent a disease. The objective of preventive medicine is to intercept or oppose the "cause" and thereby the disease process. The epidemiological concept permits the inclusion of treatment as one of the modes of intervention.

1. PREVENTION IS BETTER THAN CURE

2. SENSITIVE ISSUE
▪ Akin to Comparing Preventive Medicine with Curative Medicine

3. OXFORD ENGLISH DICTIONARY
PREVENTION
= PREVENTING FROM OCCURENCE

4. CONCEPTS OF PREVENTION
▪ It is not necessary (although desirable) to know everything
about the natural history of a disease to initiate preventive
measures. Often times, removal or elimination of a single known
essential cause may be sufficient to prevent a disease. The
objective of preventive medicine is to intercept or oppose the
"cause" and thereby the disease process. The epidemiological
concept permits the inclusion of treatment as one of the modes
of intervention.

5. LEVELS OF PREVENTION
In modern day, the concept of prevention has become broad-based.
It has become customary to define prevention in terms of four levels:
▪ Primordial prevention
▪ Primary prevention
▪ Secondary prevention
▪ Tertiary prevention

6. PRIMORDIAL PREVENTION
▪ This is primary prevention in its purest sense, that is, prevention of the
emergence or development of risk factors in countries or population groups
in which they have not yet appeared.
▪ For example, many adult health problems (e.g., obesity, hypertension) have
their early origins in childhood, because this is the time when lifestyles are
formed (for example, smoking, eating patterns, physical exercise).
▪ In primordial prevention, efforts are directed towards discouraging children
from adopting harmful lifestyles.

7. PRIMARY PREVENTION
▪ Action taken prior to the onset of disease, which removes the possibility
that a disease will ever occur.
▪ It signifies intervention in the pre-pathogenesis phase of a disease or health
problem (e.g., low birth weight) or other departure from health.
▪ Primary prevention may be accomplished by measures designed to promote
general health and well-being, and quality of life of people or by specific
protective measures.

8. PRIMARY PREVENTION
▪ The concept of primary prevention is now being applied to the prevention of
chronic diseases such as coronary heart disease, hypertension and cancer
based on elimination or modification of "risk factors" of disease. The WHO
has recommended the following approaches for the primary prevention of
chronic diseases where the risk factors are established:
▪ a. population (mass) strategy
▪ b. high-risk strategy

9. SECONDARY PREVENTION
▪ Action which halts the progress of a disease at its incipient stage and prevents complications.
▪ The specific interventions are early diagnosis (e.g., screening tests, case finding
programmers) and adequate treatment.
▪ By early diagnosis and adequate treatment, secondary prevention attempts to arrest the
disease process; restore health by seeking out unrecognized disease and treating it before
irreversible pathological changes have taken place; and reverse communicability of infectious
diseases.
▪ It may also protect others in the community from acquiring the infection and thus provide at
once secondary prevention for the infected individuals and primary prevention for their
potential contacts.

10. TERTIARY PREVENTION
▪ It signifies intervention in the late pathogenesis phase.
▪ All measures available to reduce or limit impairments and disabilities, minimize suffering caused by
existing departures from good health and to promote the patient's adjustment to irremediable
conditions".
▪ For example, treatment, even if undertaken late in the natural history of disease may prevent
squeal and limit disability. When defect and disability are more or less stabilized, rehabilitation may
play a preventable role.
▪ Modern rehabilitation includes psychosocial and medical components based on team work from a
variety of professions. Tertiary prevention extends the concept of prevention into fields of
rehabilitation.

11. REHABILITATION
▪ Rehabilitation has been defined as "the combined and coordinated use of medical,
social, educational and vocational measures for training and retraining the
individual to the highest possible level of functional ability".
▪ Rehabilitation medicine has emerged in recent years as a medical specialty. It
involves disciplines such as physical medicine or physiotherapy, occupational
therapy, speech therapy, audiology, psychology, education, social work, vocational
guidance and placement services.

12. Backend vs. Frontend measures
Frontend event measures are like
Pruning the branches of disease tree while
Backend event measures uproot the tree

13. Why big denominator?
The disease causative agent is not considered as a
component.
It is assumed that it is the whole story
Diseases are really complex
http://www.wordinfo.info/words/index/info/view_unit/1/?letter=B&spage=3

14. PREVENTION IS BETTER THAN CURE
…OR UNIVERSAL TRUTH?
SCURVY, "LIMEYS" AND VITAMIN C
James Lind 1716-94
A Treatise of the Scurvy

15. Smallpox: what value eradication?
Day 3
Synchronous
eruption of lesions
Day 5
Rash turns to
vesicles and
pustules
Day 7
Large lesions with
central well
Case fatality
30%

16. FROM INOCULATION TO VACCINATION
TO ERADICATION
Edward Jenner
(1749-1823)
Lady Mary Wortley
Montague
(1689-1762)
DA Henderson
WHO Eradication
campaign
(1966-1977)

17. Smallpox inoculation: tools of the trade

18. Cost of
eradication
in
external
funding
$125 million
"Just eradicate the disease, and
let the skeptics talk to each
other" UNICEF

19. 1967
About 10,000
cases per
month
1977
Last case 26
October 1977

20. CURE IS CLEVERER THAN PREVENTION?
186 NOBEL PRIZES FOR MEDICINE, 1901-2006
Basic science 172
Cure/therapy 12
Prevention 2
Theiler 1905
Ehrlich 1908 +
Mechnikov 1908

21. PAUL EHRLICH'S
(1854-1915)
"MAGIC BULLETS"
Prevention: "side-chain"
theory of immunity based on
antibody
Cure: drugs selectively
targeting pathogens --
arsenic-based Salvarsan to
treat syphilis
Smoking one of his "25
strong cigars a day"
Died of stroke

22. Aspirin reduces strokes in women (17%) and
heart attacks in men (32%)
women have slightly more strokes than heart attacks, men tend to have more heart
attacks than strokes (JAMA vol 295, p 306, 2005)
Sir John Vane, Nobel Prize 1982

23. IS PREVENTION BETTER THAN CURE?
In formal analysis, not necessarily…
▪ Aetiology of some diseases unknown
some conditions unpreventable
▪ Prevention vs cure is not always the right question
both are needed and feasible e.g. child mortality
in LDCs
▪ We value more than is captured in formal analysis
which gives guidance, not rules

24. PREVENTION VS CURE: A STRAW POLL AT WHO
0 1 2 3 4
Vaccination
Clean water
Handwashing
Nutrition
The pill
Seatbelts
Sterilization
Covered
cough
Vitamins
Votes for prevention
0 1 2 3 4 5
Antibiotics
Surgery
Good
doctors
ORT
diarrhea
Votes for cure

25. of aged 15 and over
are insufficiently
active
31%
Physical inactivity-
6% of deaths , main
cause for 21–25% of
breast and colon cancers,
27% of diabetes, 30%
of ischaemic heart disease
adolescent boys
use tobacco
18%
50%
continue
to smoke
7% deaths
30% NCDs due
tobacco use
adolescent are
obese
11%
Overweight & obesity -
44% of diabetes, 23%
of ischaemic heart disease
and 7-41% of certain
cancers
of adolescents
experience a mental
health problem
20%
Antisocial personality
disorder- greater than
50% of first diagnoses
across the life course are
ONLY by age 25 years
47%
experience
alcohol
dependence
of adolescent girls
and
14%
of boys reported use
alcohol.
18%
9% of all deaths in 15
and 29 age group due to
alcohol-related causes
BEHAVIORS FORMED IN ADOLESCENCE
INFLUENCE HEALTH & MORBIDITY ACROSS LIFE
continue
to be
overweight
50%
Source: WHO 2008; WHO 2009; WHO 2011

26. • UK Fire Services have long known that
prevention is better than cure
• This is why fires have reduced by more
than 50% in the last decade
• We are keen to ensure that despite
reform and budget cuts, prevention
remains at the heart of everything we
do.
• From Home Fire Safety Visits to
working to educate children and young
people. Prevention is better and less
costly than cure
KEEPING THE FOCUS ON PREVENTION

27. POLIOMYELITIS:
PREVENTION FAR BETTER THAN CURE

28. Polio vaccines
Sabin & Salk

29. POLIO ERADICATION?
>1600 CASES IN 2006
Total external spending ~ $4 bn
Initial estimate $300 million
India
Pakistan
Afghanistan
Nigeria

31. ▪ Polio Eradication & End game strategic plan (2013 – 2018) has
been developed to capitalize on a unique opportunity to
eradicate polio only the second time in the history.
▪ Cost = $5.5 billion + additional resources from the countries
▪ 1980s: polio crippled 3.5 lakh children every year ~~ fewer
than 250 in 2012
▪ Global Polio Eradication Initiative (GPEI) initiated in 1988. An
investment of $9 billion has already generated net benefits of
$27 billion.

32. Two alternatives
▪ Relying solely on the
existing routine
immunization and
control policy, to keep
the number of polio
cases below certain
level

35. WORLD HEALTH REPORT 2013
15TH AUGUST ‘13: MARGARET CHAN, DG, WHO
▪ World is spending more than USD100 billion on health research
▪ A lions share goes to the discovery and development of pharmaceutical and biotechnology
products.
▪ A tiny proportion goes into research into health systems and service delivery.
▪ Syphilis is easily screened, diagnosed and treated each costing less than $1, yet about 2 million
pregnant women are infected and half of them transmit to newborns; not to mention the dire
consequences…
▪ Cervical cancer being the third leading cause of cancer among women, it is indeed impressive to
note that there are effective vaccines: which undoubtedly lessen the burden in the future
generations!!!