Primary prevention through developing healthy communities with healthy people is the most effective and efficient way to address health. Also, enhancing well being is more effective than addressing the reduction of morbidity and mortality alone.

In other words, re-engineering the road away from the precipice will save a lot more than lives.

Prevention is LOST word today....Probably exists only in theory & in text books...World trends & statistics show that we tend to make an error rather than prevent it & of course the biggest culprit is LIFESTYLE ..a multi billion rather multi trillion global industry & craze.....Even health personnel everywhere are shying away from this vital responsibility & making trillions in trying to cure errors....God bless us

A great observation regarding the current thinking. For us public health professionals, our work starts where the thought forms shown are rife. That means we will always have work to do educating and enabling people towards seeking a healthier state through the way they live.

However, it will be noticed that our main argument that everything else serves the people's health, is gaining ground.

Thus, the day will soon come, especially as we become public health entrepreneurs, when someone will be asking us how to build their houses and offices to resist earth tremors, quakes and hurricanes or tornadoes; farmers will be asking us to help them with their crops e.t.c. Engineers will have us as partners, physicians will have us looking into their practice for them, pharmaceutical companies will ask us to help them; and even the prisoner will want to hear from us.

Certainly prevention is better than cure. The problem gets complex when we talk of behaviour. Knowledge alone does not translate to behaviour. So Public health professionals can educate, they themselves have the knowledge but that does not necessarily mean they or the people they educate lead healthy life styles.

What has to happen for a person to get to say yes I get it , I will quit smoking, I will exercise, I will not partake in risky sexual behaviours etc.? Cost vs benefit, morality, health beliefs, knowledge, culture, peer?

South Africa is experiencing a cocktail of four epidemics. HIV/AIDS/TB, Maternal and Child mortality, NCD's and Violence.

Who should put up the fence (individuals, family, society or government), where (HIV/AIDS/TB, Maternal and Child mortality, NCD's or Violence) and where do we need the ambulance, why and who is the government?

Regarding UPSTREAM & DOWNSTREAM issues related to prevention. please allow me to share my views 7 what I told my medical students during my Preventive Medicine teaching career , here in Oman.

There is a story of a man standing beside a stream ( downstream ) seeing a person drowning, jumps into the water, brings him ashore & revives him. Just as he has finished his task, he sees another person in a similiar situation & he repeats the same life saving procedures . this goes on & on & he then thinks ..HOW LONG CAN I CONTINUE LIKE THIS.

He then decides to go upstream & find what is the cause. there he sees a man pushing a person into the stream one after the other.

This is exatly the situation in today's world where we are continously toiling to save people but forgetting to ask WHY IS THIS HAPPENING & not tackling the root cause.

we can GO ON & ON saving people rather TRYING to save people..It will never END & the issue will become bigger & bigger every minute.....Sad but every country today is working on these lines & hence making every SMALL problem explode into an EPIDEMIC & PANDEMIC......All caused by human errors But not being solved correctly through PREVENTION...

If we continue to act & behave like this ..we have no option but to say ....HUMPTY DUMPTY HAD A GREAT FALL.....All the KINg's horses & all the king's men COULD NOT PUT HUMPTY DUMPTY TOGETHER GAIN....

The modern day PIED PIPER ( not of Hamelin ) is " Unhealthy Lifestyle "which is alluring us & making us follow each other blindly & dive into the sea , knowing well that we will DROWN...but we are surely not concerned...as a nation or as a world.

I agree. Is it because no one wants to take responsibility? Is the government responsible for my smoking, lack of exercise and sexual behaviour? Do we not know that if we smoke , do not exercise etc we are killing ourselves?

Who in the first place is the steward of our health?

The discuss is about making it possible or easier for the person who smokes to stop smoking. The pathway to disease causation is lined by not only the causative organism but also by biological, and more importantly, social factors. There are some social factors that make it difficult for a person to behave in a desired way and using the fence analogy would aim to improve the situation so that adopting healthy behaviour is made more possible.

For example, in relation to maternal mortality, it is not enough to say women should go to the hospital for delivery. This is unlikely to happen for a woman who does not appreciate the need for that because of low educational level of other cultural issues, or does not have the money to support the hospital visit or the social support that is needed for child care for the remaining children at home while she visits. It is also unlikely to happen for a woman who lives in a remote area with difficult access to a health facility. So such a woman who then delivers at home and developes a complication cannot be blamed for not utilizing supervised delivery services.

Now while the ambulance (in the form of timely intervention) may help this particular woman, what would help more women in her locality would be to address the fundamental issues (through social change) that surround the morbidity (and possibly mortality). In this case that would be to improve availability and accessibility to maternal health services by providing more facilities with good quality services; improve road networks to these facilities; make the services free or subsidized; and in the long run, improve the general status of the woman through education as this would make her more appreciative of the need to access these services. When these measures are put in place (the fence) you would find that fewer women would develop life threatening conditions and fewer still would die from the complication. Then the the "ambulance" would only serve as a back up to take care of thus women who would unavoidably gone over the "fence".

It would appear therefore that making the fence stronger would be a more effective strategy since it would save more lives at one go than having more "ambulances" on the stand by. Thus while it is true that people should be responsible for their action towards morbidity causation, it is also true that other non-personal factors also contribute tremendously to this process; public health practitioners should strive to bring about a positive change to the social circumstances that facilitate disease causation.

Well done and what a fantastic response Aisha.

It is great to read the consensus about prevention at a time when too many of our right wing politicians (eg USA and Australia) are weakening the efforts around prevention.

These politicians are too influenced by the big multinational fast food, alcohol and tobacco companies. The industry message is to push ‘self-responsibility’ for lifestyles so that politicians do not regulate their unscrupulous marketing.

I agree we need to continue to advocate for a comprehensive ‘health promotion’ approach (the upstream ‘fence’) rather than the downstream treatment emphasis (‘ambulance’). We need both'self responsibility PLUS regulation by governments.

This approach has worked well with tobacco control in countries like Australia and USA. It has also worked well for HIV/AIDS prevention in Australia until recently. Unless our Australian government re- finances the ‘fence’, HIV/AIDS is likely to increase once again.