PREVENTION IS BETTER THAN CURE

SENSITIVE ISSUE

▪ Akin to Comparing Preventive Medicine with Curative Medicine

OXFORD ENGLISH DICTIONARY

PREVENTION

= PREVENTING FROM OCCURENCE

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.

LEVELS OF PREVENTIONIn 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

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.

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.

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

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.

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.

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.

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

Why big denominator?The disease causative agent is not considered as a component.It is assumed that it is the whole storyDiseases are really complex

http://www.wordinfo.info/words/index/info/view_unit/1/?letter=B&spage=3

PREVENTION IS BETTER THAN CURE …OR UNIVERSAL TRUTH?

SCURVY, "LIMEYS" AND VITAMIN C

James Lind 1716-94A Treatise of the Scurvy

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%

FROM INOCULATION TO VACCINATION TO ERADICATION

Edward Jenner (1749-1823)

Lady Mary Wortley Montague (1689-1762)

DA HendersonWHO Eradication

campaign (1966-1977)

Smallpox inoculation: tools of the trade

Cost of eradication

inexternal funding

$125 million

"Just eradicate the disease, and

let the skeptics talk to each other" UNICEF

1967

About 10,000 cases per month

1977

Last case 26 October 1977

CURE IS CLEVERER THAN PREVENTION?186 NOBEL PRIZES FOR MEDICINE, 1901-2006

Basic science 172Cure/therapy 12Prevention 2

Theiler 1905

Ehrlich 1908 +Mechnikov 1908

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

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

IS PREVENTION BETTER THAN CURE?

In formal analysis, not necessarily…

▪ Aetiology of some diseases unknownsome conditions unpreventable

▪ Prevention vs cure is not always the right questionboth are needed and feasible e.g. child mortality in LDCs

▪ We value more than is captured in formal analysiswhich gives guidance, not rules

PREVENTION VS CURE: A STRAW POLL AT WHO

0 1 2 3 4

Vaccination

Clean water

Handwashing

Nutrition

The pill

Seatbelts

Sterilization

Coveredcough

Vitamins

Votes for prevention

0 1 2 3 4 5

Antibiotics

Surgery

Gooddoctors

ORTdiarrhea

Votes for cure

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

• 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

POLIOMYELITIS: PREVENTION FAR BETTER

THAN CURE

Polio vaccinesSabin & Salk

POLIO ERADICATION?>1600 CASES IN 2006

Total external spending ~ $4 bn

Initial estimate $300 million

IndiaPakistan

AfghanistanNigeria

▪ 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.

Two alternatives

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

WORLD HEALTH REPORT 201315TH 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!!!

Thank you