Hallman Lecture–Chronic disease prevention: “upstream” and “downstream” revisited, School of Public Health and Health Systems, University of Waterloo

The Hallman Lecture series and School of Public Health and Health Systems present a public lecture by John Frank MD, CCFP, MSc, FRCPC, FACHS, FFPH, FRSE, LLD; Director of Scottish Collaboration for Public Health Research and Policy, University of Edinburgh; Inaugural Scientific Director of the Canadian Institutes of Health Research – Institution of Population and Public Health

Dating back to the renowned epidemiological thinker Geoffrey Rose, the notions of “upstream” and “downstream” prevention are deeply embedded in modern public health practice. However, detailed examples, with their respective pros and cons, are harder to find.

In their new book “Prevention: A Critical Toolkit,” the presenter and colleagues offer such examples, which will be summarized in this presentation:

  • the instructive historical example of the pellagra epidemic in the US Old South, which lasted for nearly four decades of the first third of the last century, killing hundreds of thousands – even though the brilliant US Public Health Service investigator Joseph Goldberger had completed a series of novel epidemiological studies clearly demonstrating the disease’s nutritional cause and complete preventability
  • the quintessential example of a modern pandemic – obesity and overweight – against which virtually no public health evidence points to the feasibility of only downstream prevention/treatment – but for which the precise target of upstream control efforts has remained elusive;
  • the more controversial example of incentivising primary care services to more intensively screen adults with no cardiovascular disease (CVD) symptoms or history, for primary CVD prevention by indefinite daily drug treatment with statins and/or anti-hypertensives – a clearly downstream strategy with distinct disadvantages, uncertain risks, and significant costs.

The presentation concludes by reflecting on why upstream preventive interventions are typically more challenging to develop and evaluate, ending with examples of upstream-prevention research questions which are typically neglected in most developed countries’ public health research portfolios.

The lecture will be followed by a panel discussion, Q&A period, and a reception.