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Prevention

PREVENTION

The term "prevention" encompasses the philosophy, credo, programs, and practices that aim to defer or eliminate diseases, disability, and other forms of human suffering. Additional discussions of disease prevention, the stages of prevention (primary, secondary, and tertiary) and the issues of clinical prevention in the setting of personal health services can be found elsewhere in this encyclopedia. The notion of prevention in populations has a long history of discovering and eliminating the causes of disease. For example, in the 1840s Hungarian physician Ignaz Phillipp Semmelweis reduced the rates of puerperal sepsis among pregnant women through attendant hand washing. In the 1850s, British physician John Snow helped abort an outbreak of cholera in London that was due to a contaminated water supply. The gradual assumption of sanitary practices in public health and preventive activities in clinical practice has been in place for a long time and is increasing, although always challenging and incomplete.

THE CONTEXT OF PREVENTION: THE GENERAL CAUSES OF DISEASE AND DISABILITY

The causes of disease and disability are gradually being discovered and either removed or ameliorated due to scientific advances as well as clinical and preventive interventions. While there are many measures of health, one of the most basic, mortality rates, improved at an unprecedented rate during the twentieth century, providing a strong basis for optimism that new preventives and treatments will continue to enhance health status. However, many diseases and conditions and other causes of human suffering are of unknown or incompletely understood causes. While striving to optimize health status and minimize dysfunction and disability within populations and individuals, it is likely that there will always be a health and functional burden on societies. There are several reasons for this including: uncontrollable acts of nature, such as meteorological and climatic catastrophes; war and other forms of interpersonal violence; unanticipated adverse effects of advancing technology or occupational exposures; adverse effects of health interventions (even if the net health benefit is positive); the constant evolution of infectious organisms; naturally occurring errors in function, which will inevitably occur among complex biological systems, even in the absence of known environmental stimuli; the uncontrollability of individual behavior; and the unintended consequences of health-giving interventions, such as the development of resistance to antibiotics that once successfully cured a wide variety of life-threatening infections.

While public health and the medical sciences continue to develop new preventive and curative modalities, there are ecological factors and forces intimately related to diminished population and individual health that could be addressed even in the absence of clear causal or pathogenetic mechanisms. One of the most important is the close relation between socioeconomic status and health. Both within and among populations, those with higher levels of affluence and various social and economic resources in general have higher levels of health by almost all available indices. One particularly common finding is the relation between income inequality and mortality. There may be several explanations for the generally strong association between income levels and subsequent mortality: (1) higher income levels are a measure of a safer physical environment, including occupational exposures and the general environment; (2) higher income purchases more effective personal and family health services; (3) higher income and wealth levels are literal markers of social status, with lower levels being characterized by increased stress from social oppression and distrust; and (4) income and wealth are markers of increased education and healthy behaviors. It is also possible that the association occurs because individuals with physical or mental conditions have a lesser ability to earn higher levels of income and accumulate wealth.

Even in the absence of full explanations for the income-disease association, some possible solutions may be available, including social policies that limit large levels of income inequality, and expenditures on economic development, which might improve health status secondarily as well as increase access to personal health services. However, the evidence for the effects of these social and economic policies is incomplete, and additional intervention studies are needed.

Despite the presence of global factors that appear to be important forces for disease causation, and the likelihood that disease and disability will quite likely continue to be public health and clinical challenges, a substantial amount is known about the causes of many conditions, and preventive interventions are available to lessen, if not eliminate, their public health burden. When considering disease prevention, it is axiomatic that most important clinical illnesses have multiple causes. For example, deaths from certain viral infections may be caused by the lack of immunization facilities, the failure to handle and administer vaccines properly, household crowding, inadequate nutrition and lack of knowledge to seek early care when the infection appears, as well as biologic variability in susceptibility. Coronary artery disease is caused by several factors, including genetic contributions, high fat diets, cigarette smoking, elevated blood cholesterol levels, and inadequate exercise: Preventive action aimed at several of these factors should have a salient effect. Thus, interventions at several critical points in disease causationclinical, behavioral, policy, and educationalmay all decrease morbidity and mortality. In many instances, multifaceted interventions may provide the best levels of prevention rather than any single approach. A corollary principle is that a preventive intervention at one locus may help prevent several conditions. An effective clinical smoking-prevention program will decrease the risk of several heart and lung diseases.

THE CONTEXT OF PREVENTION: WHERE PREVENTION TAKES PLACE

Prevention takes place at almost all important societal venues, which may be considered in a few major categories (although there is overlap among them): (1) prevention that is facilitated by a healthful environment; (2) prevention optimized by healthful personal behaviors; (3) preventive interventions delivered by health professionalssocalled clinical prevention; and (4) prevention that occurs through social actions, including political, policy, economic, educational, and other group behaviors.

Examples of each preventive venue is instructive. A healthful physical and biological environment is attained when known harmful agents are eliminated, such as lead, automotive exhaust gases, asbestos particles, and viral infectious particles. However, it is very difficult to determine the risks to health of small amounts of certain environmental agents, naturally occurring or contaminants, and risk assessment methods may be employed. Healthful personal behaviors, such as regular, appropriate exercise programs and avoiding risk-taking behaviors, such as tobacco or illicit drug use, will add measurably to positive preventive outcomes. Clinical preventive interventions, such as cancer screening, clinical health counseling, and routine immunizing practices, will add important elements of prevention to individuals and families. Finally, social and administrative activities provide some of the best prevention available in communities. Examples include providing laws that deter underage alcohol and tobacco consumption, health system policies that promote early disease detection, and taxation policies that deter purchase of harmful products such as cigarettes and firearms. All prevention activities work in concert to provide as safe and healthful an environment as possible, but, as noted below, the secondary consequences of each activity should be understood as much as possible.

DISEASE PREVENTION AND HEALTH PROMOTION

Disease prevention is often distinguished from health promotion. While the absence of important conditions is a most worthy goal, it is also useful to consider the attainment of positive health states, where not only are clinical conditions not present, but the highest levels of physical, mental and social well-being are attained. The term "health promotion" has been used to encompass interventions and behaviors that prevent diseases, but many of these same activities can be valuable for attaining the most positive functional performances, emotional attitudes, and states of well-being, irrespective of disease occurrence and risk. Some of this may be obtained by abstinence from tobacco, regular exercise programs, consumption of lower fat diets, and provision of educational opportunities. An additional term often used in public health is "health protection." This term has been used in several contexts, but often encompasses both health promotion and disease prevention, and usually refers to the programmatic and regulatory structures that are designed to limit harmful exposures and enhance health status of particular groups or the general population.

THE POSITIVE AND NEGATIVE EFFECTS OF PREVENTIVE INTERVENTIONS

The goals of prevention would be argued by few. Fundamentally, nearly all would agree that avoiding diseases, disability, and suffering would be beneficial for the health of individuals and the public. However, the methods of prevention, even if based in scientific studies of proven efficacy and effectiveness, can be contentious, and where explicit policy, practice, or programmatic interventions are instituted, there may be substantial fiscal costs to individuals and society, as well as adverse effects and moral or ethical disputes as to the appropriateness of the interventions. It is likely that all major activities and environmental exposures in all societies have both positive and adverse effects on individual and community health, and understanding the trade-offs can be a difficult but necessary dimension of prescribing prevention programs. To elaborate this principle, examples are offered for various elements of prevention:

  • Routine childhood vaccines eliminate a substantial amount of disease and death, but occasionally have important adverse effects on the health and well-being of some individuals.
  • Many medications that are used for disease prevention, such as those which treat hypertension or hypercholesterolemia, will have predictable and well-established adverse drug reactions that can limit their use.
  • Screening for early and asymptomatic diseases will often lead to decreased morbidity and mortality from those diseases, but the screening maneuvers may lead to occasional serious adverse effects, such as perforation of the intestine during colonoscopy. Also, since most screening tests are not perfectly accurate, it is possible that someone might be incorrectly told that a test showed no abnormality when one actually existsthis individual may take inappropriate actions based on this inadvertently false or misleading information.
  • Various mechanical devices will enable some disabled individuals to extend their functional range, but the device itself might lead to occasional injuries to that individual or to others assisting him. For example, there is a real and detectable injury rate due to wheelchair use. Such use may be appropriate, but may have incumbent adverse effects.

Thus, it is important for preventive interventions not only to be effective, but also that the cost-effectiveness and benefits of these interventions be understood. Without this, the net health change may not necessarily be positive.

Some preventive interventions are controversial not because they cause some adverse effects or because they don't always work, but rather because they inadvertently promote some level of the behavior or condition they are trying to prevent. This general problem falls under a phenomenon called "harm reduction." While somewhat over-simplified, the following are examples of when and how this occurs:

  • The promotion of cigarettes that may confer less exposure to certain carcinogens and other toxins may reduce the risk of some smoking-related conditions, but fail to dissuade some persons to quit smoking altogether because of the perception that the cigarette is "safer," when in fact it may not be very safe and the overall effect is negative.
  • Needle exchange programs, which are intended to supply drug addicts with uncontaminated needles that would decrease the risk of blood-borne infections such as AIDS (acquired immunodeficiency syndrome) or hepatitis may be beneficial to those who avail themselves of this program, but may allow more needles to be available to others. How these needles would be used by others is sometimes uncertain. The existing evidence suggests that needle exchange programs do not promote illicit drug use.
  • Similarly, the distribution of condoms to demographic or other groups at high risk of sexually transmitted diseases and unwanted pregnancies may be a preventive for some, but others are concerned that this may promote increased sexual activity, with its own health and moral dimensions.

Thus, it is possible that certain preventive interventions are helpful to those who use them, but in theory, the net benefit to the population's health may not be as great as otherwise would be anticipated. The trade-offs and secondary consequences thus should be understood for any preventive maneuver.

PREVENTIVE INTERVENTIONS: UNIVERSAL OR BASED ON SPECIAL RISK

Some preventive interventions are intended for application to high-risk or special-risk individuals. Other inventions are intended for the entire population, such as routine childhood immunizations, various educational programs in primary and secondary educational settings, and the pasteurization of milk for general distribution. Some are obviously only necessary for one gender, such as cervical cancer screening for women or prostate cancer screening for men, and some are intended only for those at risk for the unhealthy exposure of interest, such as antimalarial prophylaxis for those traveling to or residing in areas where such exposure is possible. Most authorities believe that screening infants and children for increased lead exposure, using blood levels, should be reserved for those at increased risk based on environmental exposure characteristics. Risk levels are generally defined by epidemiological studies, although in many instances the evidence necessary for precisely defining risk is often incomplete. For this and other reasons, the threshold for what constitutes "increased" risk for interventions aimed at persons with increased risk does not follow any rule as to how high the risk must be before invoking that intervention. The level chosen may be related to the risk assessment (measurement) methodology, the resources to be expended, and the amount of expected benefit. Other considerations may be of a policy nature, including decisions concerning the alternative public health or preventive uses for the intended resources.

Depending on the preventive intervention, it may be deemed that all persons in a given population are at "high" risk. One important example is coronary artery disease (heart attack, stroke, and related conditions). Here the level of risk is not only stratified within the population, but also contrasts are made with other populations. Within many Western countries, even those at lower risk according to within-population standards may be at much higher risk compared to those in some developing countries where coronary artery disease is much less common. Thus, it may be deemed that all persons in certain Western countries are at "high" risk, leading to universal and more aggressive interventions across a given population. It follows from this principle that some risk levels may be characteristic of populations and not only of individuals within those populations. Public health practice should always take that into account when providing prevention programs.

While the rhetoric defining risk status doesn't lend itself to easy quantification, as previously noted, every society has identified persons by modern public health and epidemiological methods who are at "very high" risk of certain conditions. Examples include persons in certain occupations who are exposed to high levels of environmental toxins or persons with certain genetic characteristics that define very high rates of disease onset. Such situations should be addressed by rigorous preventive interventions where possible, or in the case of genetic conditions, by at least optimally defining and minimizing risk to individuals and families. Other individuals may be at high risk of various conditions by virtue of patterns of risk-taking behaviors, and at least in some instances these can be identified and modified to some extent. Persons at very high risk of conditions, often justifiably, require levels of attention and surveillance far different from others at increased risk as well as other preventive interventions. Whether intensive attention is merited depends on the evidence that disease occurrence and human suffering can be limited.

EPIDEMIOLOGY: THE SCIENTIFIC BASIS FOR PREVENTION

While clinical prevention is aimed at individual patients and patient groups, or at those with special risks, prevention in public health is generally aimed at entire, geographically defined populations. But from a global public health perspective, clinical and population prevention are intimately linked in many ways. Patient groups sustain all of the general exposures and risks of others in a defined community, and thus require the same preventive interventions as those who are not patients. In fact, many important disease-causing factors are characteristics of communities only, and not of individuals, such as ambient air pollution levels or the availability of high-quality fire protection and health education programs in secondary schools. Conversely, many elements of population health promotion and disease prevention, such as behavioral modification programs and immunizations, are performed within the health care system, which is obviously a critical component of population health. Since nearly all citizens of communities are also health care patients at some point in their lives, reconciling the population and patient domains is necessary.

Epidemiology is the science that provides the rationale and quantitative basis for preventive interventions in both patients and communities, and in turn evaluates the effects of those interventions. This discipline describes the health characteristics and status of groups and populations, as well as their trajectories and outcomes, and quantifies the impact of various environmental exposures and personal factors on the occurrence of important health conditions. Epidemiology is largely an observational science, in that it observes disease population occurrence and environmental exposures, deduces causal pathways and mechanisms, and suggests control procedures. But it includes a strong element of randomized trials and other experimental designs where possible, such as in evaluating the efficacy of a vaccine. To do its work, epidemiology draws heavily from many other sciences and disciplines that inform health status and outcomes, such as clinical medicine, demography, behavioral science, microbiology, toxicology, administrative science, genetics, and molecular biology. As noted, this is testimony to the multifactorial nature of disease causation and the need for multidisciplinary approaches to disease prevention and health promotion. An example of cross-disciplinary activity within epidemiological disease control programs is the application of social marketing. This is an approach to communicating and disseminating health information to the community for behavioral change, using the techniques of commercial marketing. Examples of public health campaigns and programs that have used these techniques are promoting condom use among sexually active teenagers and the use of the "designated driver" in an attempt to decrease alcohol-related auto crashes and injuries.

Epidemiology's tasks usually require the calculation of disease rates, which in turn requires both a numerator (accurate disease counts), and a denominator (the population at risk for health change). Critical to both is accuracy. The population denominator, whether whole communities, important demographic segments, or groups of patients in clinical settings, must be understood. For groups defined administratively, such as patients in a hospital or clinical system, record systems will usually furnish adequate counts. For geographically defined populations, an accurate census is critical, and may not always be available. Even within industrialized nations, high levels of population migration or undocumented persons and lack of cooperation with the census in general may lead to population undercounting, often most acute for groups comprising the most important public health constituency. In many instances, effective epidemiological and public health practice requires population counts and assessments more accurate than those obtained by conventional means, employing network and other sampling or estimation techniques.

In addition to accurately determining the size of geographically defined populations, demographic trends in the United States and other industrialized countries are instructive for their effects on disease occurrence and public health. Perhaps the two most important trends are the increase in total population, although not to the extent this is occurring in developing countries, and the "aging" of populations, where the proportion of older persons is increasing relative to other age groups. Increasing population size has clear implications for environmental quality; the availability of basic resources, such as energy, transportation, and water; the transmission of infectious agents; and the nature of social interactions, which can have both negative and positive health effects. An older population similarly will have complex health effects. In general, rates for felonies and sexually transmitted diseases will be lower, but the number of cases of the chronic illnesses of older persons, such as coronary disease and stroke, cancer, diabetes, arthritis, and dementia, will likely increase. Also, since there is a progressively lower proportion of working-age persons, this may put stresses on national and regional economies, and in turn on population health status.

These demographic shifts will change the nature of prevention programs. There may be more emphasis on the prevention and early detection of the chronic conditions of older persons, and somewhat less emphasis on the conditions of younger persons, although all are important. Lower birth rates may shift resources away from maternal and child health programs toward the prevention of disability. The trend toward higher population size, improved survivorship, lower fertility rates, and a higher proportion of elders, the so-called epidemiologic transition, is occurring among many developing countries and over time will most likely shift their disease rates and prevention priorities in a similar direction to that of developed countries.

Determining the numerators for groups and defined populations (counting the diseases, conditions, and other health states in those populations) goes under the general heading of "surveillance." This takes many forms, and knowledge on disease occurrence and health status in many populations is often, at best, incomplete. For example, if a condition is never diagnosed, or if a sick individual doesn't seek medical care, then a clinical event usually remains unknown. Surveillance may be considered in two general categories: active and passive. In the former, information is collected by actively searching for disease occurrence, such as through population surveys, medical record review, and disease marker determinations in population samples. In the latter, reports are accepted from routine reporting and other voluntary sources, irrespective of whether disease reporting is a community regulation or law.

Depending on the condition, different types of surveillance techniques become most important. Historically and currently, communities have designated a set of diseases and conditions that, when medically recognized, should be reported to public health or other medical authorities. Most of these are infectious and communicable conditions, but chronic illnesses are often represented, as can any condition that might be a threat to population health. Many conditions are detected only with appropriate serological or microbiological laboratory techniques, such as many infectious and communicable conditions. Without these techniques, the infections usually would not be precisely identified and control measures executed. Thus, the public health laboratory becomes an indispensable part of a surveillance system. Laboratory ("biomarker") surveillance for some communicable diseases may be routinely performed irrespective of human clinical illness, such as by routine monitoring of sylvatic animals or patients who present to emergency rooms with any relevant clinical syndrome. Some chronic illnesses all require laboratory confirmation, such as accurate histopathology for cancer cases.

Surveillance systems may operate with other techniques, such as clinical record review. While ethical and privacy issues may deter some disease detection, this can be a very important tool for early identification of conditions with public health and preventive import. For those conditions that are not brought to medical attention or for which a diagnosis is not made, the most common approach would be population sample surveys. Here, representative samples would be interviewed or otherwise studied in an attempt to determine the prevalence and incidence of conditions not otherwise detected, or among persons not availing themselves of medical care. Population surveys also afford the opportunity to determine rates of personal behaviors and exposures that are related to disease causation, and further target disease control programs. Special studies on these population samples may reveal physical, mental, dental, or other disorders and form the basis for targeted preventive interventions. The same surveillance systems that define populations at risk and the nature and extent of preventive programs can continue to determine population disease rates as preventive interventions are invoked and applied as part of public health program evaluation.

Robert B. Wallace

(see also: Demographic Transition; Disease Prevention; Epidemiologic Transition; Epidemiology; Notifiable Diseases; Prevention Research; Preventive Health Behavior; Preventive Medicine; Primary Prevention; Registries; Secondary Prevention; Surveillance; Tertiary Prevention )

Bibliography

Centers for Disease Control and Prevention (1999). "Framework for Program Evaluation in Public Health." Morbidity and Mortality Weekly Report 48(11):140.

Lynch, J. W.; Smith, G. D.; and Kaplan, G. A. (2000). "Income Equality and Mortality: Importance to Health of Individual Income, Physiosocial Environment or Material Conditions." British Medical Journal 320:12001204.

Teutsch, S. M., and Churchill, R. E., eds. (1999). Principles and Practice of Public Health Surveillance, 2nd edition. New York: Oxford University Press.

Tyler, C. W., Jr., and Last, J. M. (1998). "Epidemiology." In Maxcy-Roseman-Last Public Health and Preventive Medicine, 14th edition, ed. R. B. Wallace. Stamford, CT: Appleton and Lange.

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prevention

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Prevention

Prevention

The use of alcohol, tobacco, and other drugs—whether legal or illegal—by various age groups and special populations continues to be a

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problem in the United States. The use of illegal drugs increased among American adolescents throughout the 1990s, and this increase caused special concern. In response, the American public has become increasingly interested in the concept of prevention. The prevention movement began in the 1970s and has gained in popularity since then. Parents have organized to address the factors that lead to substance abuse, in order to prevent drug use among young people. In many cases, youth groups have also formed to help parents prevent sub- stance abuse among young people and their peers. Supporters of the prevention movement emphasize that preventing substance abuse has a greater chance of success than helping people quit after they have become addicted. They also point out that prevention is less costly than treatment programs.

Parent groups have used several strategies to prevent their children from using drugs. One of these strategies is to change laws they see as harmful to children. For example, parent groups mounted an intensive effort to obtain laws to ban the sale of drug paraphernalia . In the early twenty-first century, nearly every state had such laws. These groups also battled with supporters of the legalization of marijuana. In general, parent groups focus on ensuring that drug- education materials convey a no-use message, rather than recommending the "responsible use" of drugs that are both illegal and harmful.

Another area of parents' concern is alcohol abuse. Families of young people killed by drunk drivers organized groups such as Mothers Against Drunk Driving (MADD), Remove Intoxicated Drivers (RID), and Students Against Drunk Driving (SADD)—now Students Against Destructive Decisions—to prevent accidents involving alcohol. As with the parent-led, drug-free movement, parents who led the anti-drunk-driving movement first raised the nation's awareness about the problem and then developed strategies to address it.

See Organizations of Interest at the back of Volume 3 for address, telephone, and URL.

Another concern of the prevention movement is the glamorization of drug use on television, in films, in song lyrics, and on the Internet—all influences on young people. Media groups have formed to address public concern about these influences. For example, the Entertainment Industries Council has developed programs to work with film makers to educate them about substance abuse and to encourage them to deglamorize drug use in movies. The National Academy of Television Arts and Sciences has taken steps to increase the industry's awareness of the impact it could have on reducing sub- stance abuse through the power and reach of the mass media. Since the mid-1980s advertising and public relations agencies have worked together in the Partnership for a Drug-Free America. These agencies volunteer their talent and time to create and produce antidrug commercials targeted at young people.

Since its origins in the 1970s, the prevention movement has spread to the military, the business community, schools, and the religious community. Ethnic and cultural groups, worried about the use of drugs by their members, have created prevention groups as a way to strengthen their communities. Local, state, and national political leaders have created policies and allocated resources to stem the flow of drugs into the country and to help people prevent substance abuse in their families and communities. The AIDS -prevention community has joined the substance-abuse prevention community in order to stop the spread of the disease among drug users.

Prevention services and policy changes have reduced the regular use of alcohol, tobacco, and other drugs in the communities they serve. These communities have benefited in several ways: fewer highway

Drug Age Group 1979 1992 1999 2000
Any Illicit Drug Young Adults 38.0% 13.1% 18.8% 15.9%
  Seniors 38.9% 14.4% 25.9% 5.5%
  Youth 16.3% 5.3% 9.0% 9.7%
Marijuana Young Adults 35.6% 10.9% 16.4% 13.6%
  Seniors 36.5% 11.9% 23.1% 3.0%
  Youth 14.2% 3.4% 7.0% 7.7%
Cocaine Young Adults 9.9% 2.0% 1.9% 1.4%
  Seniors 5.7% 1.3% 2.6% 0.4%
  Youth 1.5% 0.3% 0.7% 0.6%
Alcohol Young Adults 75.1% 58.6% 60.2% 62.4%
  Seniors 71.8% 51.3% 51.0% 58.3%
  Youth 49.6% 20.9% 19.0% 16.4%
Cigarettes Young Adults 42.6%* 41.5% 41.0% 38.3%
  Seniors 34.4% 27.8% 34.6% 24.2%
  Youth 12.1%* 18.4% 15.9% 13.4%
*These figures are taken from the Overview of the 1991 National Household Survey on Drug Abuse. Final data were eliminated from later versions of the survey, and no information about cigarette use is available for youth or young adults for 1979.

accidents involving alcohol; improved general health because of tobacco prevention; and decreased rates of criminal activity involving illegal substance abuse. Although government policy in the United States still tends to emphasize law enforcement and treatment as a way to control substance abuse, the idea of preventing substance abuse before it starts has gained in public popularity. The prevention movement seeks to create communities in which individuals and families can live healthy lives free of drug abuse and addiction and the problems they cause.

The Principles of Prevention

Over the years, those involved in the prevention movement have developed the following guiding principles for prevention programs:

1. Reduce or eliminate so-called risk factors—factors that increase a person's risk for substance abuse. Many factors increase the chances that some individuals will become substance abusers. Prevention programs recognize the following risk factors for substance abuse:

  • little commitment to school and education
  • academic failure
  • early antisocial behavior, aggression , and hyperactivity
  • alienation, rebelliousness, and lack of social bonding to society
  • antisocial behavior in early adolescence
  • favorable attitudes toward drug use
  • early first use of drugs
  • family history of alcoholism, antisocial behavior, or criminal behavior
  • parental drug use and positive attitudes toward use
  • friends (peers) who use drugs

2. Promote and enhance "protective factors"—factors that help a person avoid substance abuse. These include:

  • high self-esteem and self-discipline
  • advanced social and problem-solving skills
  • positive, optimistic outlook on life
  • easy-going temperament and affectionate personality
  • adequate family income
  • structured and nurturing family
  • promotion of learning by parents
  • warm, close relationship with parents
  • little marital conflict between parents
  • low prevalence of neighborhood crime

3. Provide services that meet the needs of individuals as well as their families. When families receive training in relationship and parenting skills, the children in these families have fewer substance use problems. Services for individuals at risk of substance abuse or who have already become users include education, intervention, and referral to treatment when necessary. For people in high-risk substance-abuse environments, prevention programs offer further services such as health care, nutrition counseling, and prenatal care.

4. Teach people about substance abuse, guide them to the available services, and teach them how to manage their own lives. When a person becomes knowledgeable about the effects of alcohol, tobacco, and other drugs, this knowledge leads to better decision making. Prevention programs can encourage people to make good decisions and to cope with life's challenges. People with substance-abuse problems learn that they are engaging in risky behaviors, and are given accurate information about the risks of substance abuse. They acquire skills for resisting peer pressure to use drugs and learn how to resist the influence of advertising on their choices. They also learn where to turn when they need help.

One prevention program that is based on the above principles is called Life Skills Training (LST). The main goals of the LST program are: (1) to provide students with the information and skills they need to resist peer pressures to use drugs; (2) to help students develop independence, self-esteem, and self-confidence; (3) to help students cope with feelings of anxiety produced by social situations; (4) to increase students' knowledge of the negative consequences of drug

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use and of the rates of tobacco, alcohol, and marijuana use; and (5) to promote a lifestyle that excludes drug use.

5. Encourage communities to establish standards of behavior through enforcement of clear policies. Communities that establish positive standards of behavior regarding alcohol, tobacco, and other drug use have been successful in delaying the onset of use. Such communities have taken steps to decrease access to substances by children and adolescents. These steps include setting rules for the location of alcohol advertisements. Community prevention programs can also teach middle-school students how to refuse an invitation to use drugs or other substances. Parents can learn how best to supervise their children in order to prevent the negative influences of peers.

Many communities also face the growing problem of heavy drinking by college students. This problem not only affects campuses and students, but also residents living near college campuses. A 2002 study found that, on an annual basis, drinking by college students between the ages of 18 and 24 contributes to an estimated 1,400 student deaths, 500,000 injuries, and 70,000 cases of sexual assault each year. The study also found that one-fourth of college students in this age group have driven under the influence of alcohol in the past year.

The National Institute on Alcohol Abuse and Alcoholism recommends that college administrators adopt the following policies, in order to reduce excessive alcohol consumption in and around college campuses:

See Organizations of Interest at the back of Volume 3 for address, telephone, and URL.

  • reinstating Friday classes and exams to reduce Thursday night partying; possibly scheduling Saturday morning classes
  • offering alcohol-free, expanded late-night student activities
  • eliminating keg parties on campus where underage drinking is common
  • establishing alcohol-free dormitories
  • employing older, salaried resident assistants or hiring adults to fulfill that role; currently, resident assistants are usually students who serve in a supervisory role in the dormitory in exchange for lower tuition
  • further controlling or eliminating alcohol at sports events and prohibiting tailgating parties where heavy alcohol use is standard practice
  • refusing sponsorship gifts from the alcohol industry to avoid giving any impression that underage drinking is acceptable
  • banning alcohol on campus, including at official faculty and alumni events

Conclusion

Certain misunderstandings about substance abuse have slowed the progress of the prevention movement. Some people believe that sub- stance abuse cannot be prevented because it is a problem passed down through genes. Clearly, genetic and other biological factors contribute to the occurrence of substance abuse. But a person's social environment also has a great impact on whether he or she will turn to drugs. Prevention can address those influences and can play an important role in responding to the problem of drug use and abuse. Federal, state, and local governments need to ensure that the best practices in prevention and education are provided to all ages.

see also Adolescents, Drug and Alcohol Use; Binge Drinking; Media Representations of Drinking, Drug Use, and Smoking; Prevention Programs; Risk Factors for Substance Abuse; Substance Abuse and AIDS.

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Prevention

Prevention

Whenever the crime of genocide or crimes against humanity have occurred, the international community and human rights nongovernmental organizations (NGOs) have asked themselves whether the developments that led to the atrocities could have been anticipated and possibly prevented. They question why no attempts had been made by the state involved, its society, or the international community at large to stop the carnage or events leading up to the genocide. Even if the perpetrators are later brought to justice, their sentencing cannot redress the human tragedy associated with the genocidal acts or the suffering of each individual. In most cases of genocide after World War II, the possibility of human tragedy could have been foreseen. Despite this reality, no fully convincing strategy has yet been designed to effectively prevent genocide. In fact, it remains an open question whether such a strategy can be developed given the complex social, economic, cultural, and psychological issues that may lead to genocide.

Existing means of preventing genocide or of preventing serious and widespread human rights violations that may lead to genocidal acts may be grouped, general speaking, into two categories: procedural and substantive ones. The former embrace all of those techniques developed by human rights institutions, which, for example, provide for the monitoring of human rights situations. The latter embrace nonprocedural obligations of states and individuals, such as the prohibition of incitement to racial hatred or the prohibition of racist organizations. Providing for criminal prosecution of acts of genocide, related acts, or acts that may create an environment that is or may become a fertile ground for genocide also has preventive effects. The threat of criminal prosecution not only labels certain human behavior as morally and socially unacceptable but also attempts to establish a psychological barrier that may prevent a potential perpetrator from taking criminal action.

All attempts to develop an effective system for eliminating genocide and crimes against humanity face one significant problem. Despite many attempts, there is no agreement on which factors may lead to such acts. Certain scholars have made reference to human destructiveness leading to instinctual aggression, to humankind's intraspecific warfare, and to human destructiveness developing from the fear of death. These attempts to explain the unthinkable are rather academic. The restructuring of the human psyche is not a workable solution, even if warfare or human destructiveness is assumed to be part of the human character. One has to proceed to a different level of assessment, and attempt to answer the question: What are the social, cultural, religious, political, or economic conditions under which instinctual human aggression may find its expression in genocidal or related acts?

Factors Likely to Induce Genocide

There is no single explanation of why a government and a society pursue a policy of genocide or crimes against humanity. In most cases throughout history, genocide or related acts were not the result of sudden decisions but, as with the Holocaust, the result of ideological and political preparation and indoctrination. Particular groups are identified as inferior or somehow unworthy in a given society. Such identification of a group of people may be initiated by that part of the society or the government preparing for genocide. Alternatively, or additionally, the identification of a particular group or groups within a larger community can be the result of an act of self-identification of that particular group or groups with the view to preserve its cultural, linguistic, religious, or historical particularity.

Such self-identification as a group is protected under international law. Under the ever increasing relevance of human rights, the world has become aware of the fact that states are neither ethnically and culturally homogeneous, nor is there any merit in being so. In fact, attempts to create ethnically homogeneous states in the aftermath of the dissolution of the former Yugoslavia have resulted in the term "ethnic cleansing," an activity related to genocide.

The branding of a particular, targeted group as being inferior or dangerous for another part of the community, or the stability of the respective state, is the first clear indicator of a situation that may lead to genocide. Even the development and fostering of negative feelings or stereotypes within a society against individual members of a group just because they are members of that group should be considered a warning signal. It would be naive, however, to believe that only the dominant group in a given society could stimulate misunderstandings and tension; the later targeted group may contribute to feelings of alienation by excluding itself from the society, by conveying an attitude of superiority, by giving the impression of not being loyal to the state it lives in, or by advocating its secession from the given state. Frequently the attempt is made to rationalize the perceived difference or inferiority of the targeted group or the superiority of the dominant group by developing pseudo-scientific theories. This was particularly true for the German policy leading to the Holocaust. The development of such theories and their publication should also be considered a potential precursor to genocidal or related acts.

What is the mechanism that makes the dominant part of a society take action against a particular group? Several historians offer explanations. Individuals such as Leo Kuper hold that material interests may be an important factor in the development of genocide. This may be true in cases where a particular group is occupying an area that is of significant interest for the economic well being of the region or country. This is a situation indigenous groups have faced and are still facing; for example, the repression of the Native Americans or the Australian aborigines was mostly economically motivated. Expelling indigenous populations or even transferring them to other areas may take the form of or may result in genocide.

However, economic interests may have little or no significance in the genocide against targeted groups that are singled out for purely ideological reasons. Economic factors were irrelevant, for example, in the German genocide against Gypsies, which was motivated by pure malevolence and historical prejudices. In fact, prejudices can exist and may even become quite virulent—even in societies where Jews and Gypsies do not play any significant role in the society or where they do not exist at all. Perhaps it is most appropriate to say that aggressive attitudes toward particular ethnic or religious groups are likely to materialize in times of a society's transition, when it faces an identity crisis, or when it is in the midst of economic crisis.

Factors Likely to Prevent Genocide

Having touched upon situations that are more likely to bring about aggression against a particular group in a given society, it is worthwhile also to touch upon situations that are more immune to such development.

History has shown that the attitude of singling out a particular spectrum of the society develops less in societies that are pluralistic and used to be so. Equally democratic societies are usually less vulnerable to genocide. Given the wave of xenophobic and anti-Semitic attitudes western European countries are facing, it would be credulous to believe that democratic societies are absolutely immune from anti-Semitic, xenophobic, or related attitudes. It is essential that states—apart from their form of organization—are socially and economically stable. All occurrences of genocide in modern times have taken place at times when states underwent significant transitions and thus lost their previous identity, or perceived it as endangered. For example, the progressive disintegration of the Ottoman Empire was one of the causes of the aggression against the Armenian population. Likewise, the destabilization of Germany and Austria after World War I facilitated and fuelled the growth of anti-Semitic feelings.

Genocide only takes place when it is organized by a state, endorsed by state authorities, or approved of by the majority of the dominant members in a society. Therefore, preventive actions either have to strive for the immunization of the society against any attempts to make any group a target for discrimination or suppression, or to provide interventions from the outside if such developments are about to unfold in a given society.

Preventive Measures under the Genocide Convention

The Convention on the Prevention and Punishment of the Crime of Genocide, also referred to as the United Nations' Genocide Convention (1948), refers both to prevention and to the punishment of the crime of genocide, however, the Convention focuses on the second aspect rather than on the first. The concept of prevention is repeated in Article 1 of the Genocide Convention, however, no particular consequences follow. Nevertheless, the punishment of the crime of genocide or even the threat to punish it is meant to have a preventive effect. In that respect the Genocide Convention is not different from national criminal law. Apart from that, some of the acts referred to in Article 3 of the Genocide Convention have a preventive dimension. The prosecution of conspiracy, or of attempts of public incitement to commit genocide, is an attempt to fight future occurrences of genocide. Another preventive element can be found in Article 8. According to that provision, any contracting party may call upon the competent members of the United Nations to take such action as considered appropriate for the prevention and the repression of acts of genocide.

This rudimentary mechanism is all that remained from a more substantial provision in the draft of the Genocide Convention prepared by the secretariat. According to the scholar Nehemiah Robinson, the secretariat draft contained an elaborated prevention mechanism. Article 12 of that text, which was titled "Action by the United Nations to Prevent or to Stop Genocide," stated that, irrespective of the deterring function of penalizing genocide, contracting parties may have the right to call upon the competent organs of the United Nations to take measures for the suppression and prevention of such crimes. The secretariat obligated states to do everything in their competence and support any actions of the United Nations to prevent or to stop genocide. In particular, the United States had some doubts about these provisions whereas the Soviet Union pushed for an even stronger formulation that would have obliged all states to report genocide to the Security Council. The consequence would have been that measures could have been taken in accordance with Chapter 7 of the United Nations (UN) Charter. In 1973 the provision of Article 8 of the Genocide Convention was included in the Convention against Apartheid.

Scholarly opinions differ as to the relevance of Article 8 of the Genocide Convention. Several writers dismiss its relevance. Others, such as Hans-Heinrich Jescheck, have indicated that Article 8 provides the Security Council with a basis to take action, which, in view of Article 2 of the UN Charter, was necessary to include. This argument was based upon the assumption that the Security Council could only act in cases or situations falling under Article 39 of the UN Charter and that genocide or crimes against humanity could not be qualified as such. However, because the Security Council has developed the practice that significant and widespread human rights violations may be qualified as a threat to international security, Article 8 of the Genocide Convention has lost some of its relevance.

Despite these elements that refer to prevention, the Genocide Convention has shied away from providing a genuine mechanism for the prevention of genocide. The reasons for that are open to speculation. The prevailing reason might be the fear that any attempt to set up the respective mechanism would mean an infringement into the internal affairs of a state and an erosion of Article 2, paragraph 7 of the UN Charter as it was understood in 1948. Only the increasing relevance of international human rights standards—which was initiated with the Universal Declaration on Human Rights and the Genocide Convention—has changed international law in this respect. Meanwhile it is untenable to argue that serious violations of internationally protected human rights are an internal affair of any given state. The international community of states may intervene or may be under an obligation to take action to redress the situation.

Preventive Measures under Different Human Rights Agreements

The Human Rights Committee, the Committee on Economic Social and Cultural Rights, the Committee on the Rights of the Child, and the Committee on the Elimination of Racial Discrimination have adopted procedures on preventive action. These include early warning and urgent procedures as a guide for the committees' future work concerning possible measures to prevent in a more effective way any violation of the respective conventions. This includes actions taken to prevent genocide, and even a situation that may lead to genocide. This approach was taken upon the recommendation of the UN General Assembly in the context of the Agenda for Peace. As far as conceptuality and the implementation of such procedure are concerned, the Committee on the Elimination of Racial Discrimination has developed the most systematic and far-reaching practice. Like the other human rights treaty bodies, the Committee was particularly induced to establish such a procedure by the events in the former Yugoslavia and in the Grand Lakes Region of Central Africa. The members of the Committee felt that the regular monitoring of the human rights situation in these regions had proven to be inadequate to prevent the occurrence or reoccurrence of genocide.

Preventive actions of the Committee on the Elimination of Racial Discrimination include early warning measures to address existing structural problems that might escalate into conflicts. Such a situation calling for early warning is warranted when the national procedures for the implementation of human rights are inadequate or there exists the pattern of escalating racial hatred and violence, racist propaganda, or appeals to racial intolerance by persons, groups, or organizations, notably by elected or other officials. The criterion for initiating an urgent procedure, according to the decision of the Committee, is the presence of a pattern of massive or persistent racial discrimination.

The reaction in its preventive functions and in response to problems requiring immediate attention are similar under all the early warning procedures. The Committee on the Elimination of Racial Discrimination will first exhaust its advisory function vis-à-vis the respective state party. The Committee may address its concern, along with recommendations for action, to all or any of the following: the state party concerned, the special rapporteur established under a Commission of Human Right Resolution, the Secretary-General of the UN, and all other human rights bodies. The information addressed to the secretary-general may, in the case of urgent procedures, include a recommendation to bring the matter to the attention of the Security Council. In this case the Committee may appoint a special rapporteur.

An important mechanism of a nonprocedural character meant to prevent racial discrimination and genocide is the obligation of states to prohibit hate speech and to ban organizations advocating racial intolerance. The Genocide Convention lacks a provision to address this, although other human rights instruments have addressed issues of hate speech.

Article 7 or the Universal Declaration of Human Rights, adopted the day after the Genocide Convention, contains a rudimentary reference to limitations to the freedom of speech by protecting against the incitement of discrimination. Article 29 of the Universal Declaration further opens the possibility for states to limit the enjoyment of fundamental rights and freedoms, including the freedom of expression, for the purpose of securing due recognition and respect for the rights and freedoms of others and for meeting the just requirements of morality, public order, and the general welfare in a democratic society. This covers limitations on the freedom of speech with the view to eliminate hate speech and hate propaganda as well as a denial of the Holocaust.

A more focused provision obligating states to limit freedom of speech is contained in the Convention on the Elimination of All Forms of Racial Discrimination. The Committee considered this provision to be of prime importance for the implementation of the Convention against racial discrimination. According to the provision, it is mandatory that states not only enact appropriate legislation—which, in fact, means enactment of criminal law—but also ensure that such criminal law is effectively implemented. The said provision equally obliges state parties to the Convention against Racial Discrimination to prohibit organizations with a racist program and make the participation therein a criminal offense. The Committee has frequently emphasized the importance of this provision, although several states have stated that their constitution would not allow them to prohibit and dissolve such organizations. Those state parties that for reasons of their national legal order cannot implement this obligation are called upon to be of particular vigilance. This provision raises particular legal problems in respect to political parties promoting racist ideologies because the dissolution of political parties may be the means to preserve the domination of a ruling regime. Under the conditions of a democratic society, it may be argued that it is preferable to fight racist attitudes and ideologies within the framework and the means of a democratic discourse rather than through repressive means. Past experience, however, proves that in periods of transition and of economic or political instability this may not be effective enough to protect the society from racial tensions or racially motivated violence.

The International Covenant on Civil and Political Rights also contains provisions providing for the limitation of fundamental rights, including the freedom of expression and of association, which may be used to prevent the incitement of racial hatred or violence. The Covenant recognizes that the human right of freedom of expression is subject to special duties and responsibilities. It imposes an obligation upon states to prohibit any adversarial speech of national, racial, or religious hatred that constitutes incitement to discrimination, hostility, or violence. Further, the Covenant provides for restrictions to the freedom of expression by law necessary to respect the rights and reputations of others or for the protection of national security or of public order. This would cover hate speech and hate propaganda as referred to in Article 20 of the Covenant. Although the European Convention on Human Rights does not include an obligation to prevent hate propaganda, it is held that hate propaganda is not protected by Article 10 of the Convention, which includes freedom of expression. In the Jersild v. Denmark case in 1994, the European Court of Human Rights agreed that the freedom of expression provision of the European Convention on Human Rights should be interpreted, "to the extent possible, so as to be reconcilable with its obligations" under the International Convention for the Elimination of Racial Discrimination. The freedom of speech provision in the American Convention on Human Rights is broader than in the other international instruments. However, despite its large vision of freedom of expression, the provision also contemplates the case of racist propaganda. Article 13, paragraph 5, of the Convention is more or less identical with Article 20 of the International Covenant on Civil and Political Rights.

Whereas Article 4 of the International Convention on the Elimination of all Forms of Racial Discrimination obliges states to take action against "incitement to, or acts of such [racial] discrimination" the United Nations Educational, Scientific, and Cultural Organization (UNESCO) Declaration on Race and Racial Prejudice addresses the root problem of racial prejudices. It reaffirms that all human beings belong to a single species and are descended from a common stock; they are born equal in dignity and all form an integral part of humanity. The Declaration further emphasizes that all individuals and groups have the right to be different, to consider themselves as different, and to be regarded as such. However, the diversity of lifestyles and the right to be different may not, in any circumstances, serve as a pretext for racial prejudice. Apart from stating these principles and declaring theories on racial superiority or inferiority as being without scientific foundation, the Declaration is moot when it comes to describing actions to be taken by states.

The aforementioned measures discussed are of a "repressive" nature, in as much as they provide for the criminal prosecution of genocide or for the prosecution of preparatory acts as provided for in Article 3 of the Genocide Convention or for the repression of acts that may prepare the political or ideological ground for inter-ethnic strife or intolerance. Less attention has been paid to measures meant to positively influence society, such as education and information.

Positive measures are touched upon in Article 7 of the Convention on the Elimination of all Forms of Racial Discrimination. The Convention does not outline specifically the appropriate actions for states to take. Most social scientists agree the teaching of human rights, in general, and the principles enshrined in the UNESCO Declaration on Race and Racial Prejudice, in particular, should be included into the curriculum of schools at all levels. Many call for curriculum that includes information on the Holocaust and other occurrences of genocide or similar events after World War II. However, it is up to individual states to develop mechanisms that are most suitable for the education of tolerance. The UNESCO Declaration on Fundamental Principles concerning the Contribution of the Mass Media to Strengthening Peace and International Understanding, to the Promotion of Human Rights and to Countering Racialism, Apartheid and Incitement to War (1978) refers to the role mass media may play in stigmatizing genocide.

Conclusion

Democratic societies that perceive themselves as pluralistic and those societies that believe that ethnic or religious pluralism is an enrichment rather than a weakness are less likely to fall under the spell of racist theories. The Genocide Convention is meant not only to prosecute those having committed the crime of genocide but also to prevent the development of genocide. Later international human rights instruments place a heavy emphasis on preventing genocide by providing states with the means to suppress attitudes or ideologies of racial superiority. Historians agree that more emphasis should be placed on educational efforts; for example, helping children strive for a better understanding of the world's different cultures, lifestyles, and religions. Other historians have suggested an effective system for the protection of minorities.

SEE ALSO Denial; Early Warning

BIBLIOGRAPHY

Banton, Michael P. (1996). International Action against Racial Discrimination. New York: Oxford University Press.

Banton, Michael P. (2002). The International Politics of Race. Malden, Mass.: Blackwell.

Charny, Israel W. (1987). How Can We Commit the Unthinkable? Genocide: The Human Cancer. Boulder, Colo.: Westview Press.

Coliver, Sandra, ed. (1992). Striking a Balance: Hate Speech, Freedom of Expression, and Non-discrimination. Colchester, U.K.: Human Rights Center, University of Essex.

Fein, Helen (2001). "The Three P's of Genocide: With Application to a Genocide Foretold—Rwanda." In Protection against Genocide: Mission Impossible? ed. Neal Riemer. Westport, Conn.: Praeger.

Jescheck Hans-Heinrich. (1995). "Genocide." In Encyclopedia of Public International Law, vol. 2, ed. Rudolph Bernhardt. New York: North-Holland.

Koestler, Arthur (1978). Janus: A Summing Up. New York: Random House.

Kuper, Leo (1985). The Prevention of Genocide. New Haven, Conn.: Yale University Press.

Lieblein, Julius (1987). "The Bottomline: Preventing Future Holocausts." In Toward the Understanding and Prevention of Genocide: Proceedings of the International Conference on the Holocaust and Genocide, ed. Israel W. Charny. Boulder, Colo.: Westview Press.

Lorenz, Konrad (1977). On Aggression. New York: Harcourt, Brace and World.

O'Flaherty, Michael (1996). Human Rights and the UN: Practice before the Treaty Bodies. New York: M. Nijhoff Publishers.

Robinson, Nehemiah (1960). The Genocide Convention: A Commentary. New York: Institute of Jewish Affairs.

Schabas, William A. (2000). Genocide in International Law: The Crimes of Crimes. New York: Cambridge University Press.

Scherrer, Christian P. (2001). Preventing Genocide. Moers, Germany: Venlo.

Zimmer, Anja (2001). Hate Speech im Völkerrecht, Europäische Hochschulschriften, vol. 3302. Frankfurt: A. M. Lang.

Rüdiger Wolfrum

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