The "River Story" is a common way to describe primary prevention. This story is also often called "The Upstream Story." It highlights the need to address the roots causes of a health problem. Some attribute it to the community organizer Saul Alinsky. Some people refer to it as a traditional story or as the "public health parable."

Examples

  • To introduce "Primary Prevention" I tell the "upstream/downstream" story, then using two pieces of tape or a length of rope or something, show a continuum (river) on the floor, and ask people to move to where they think an example of prevention belongs - you can either read the examples aloud and have everyone move for each one (my preferred way, it's more kinesthetic and it fosters discussion) or hand out cards with different examples on them and each person only stands in one spot (where they think their example belongs). You can insert "secondary prevention" into the story, before the rescuers head upstream (primary prevention). "The rescuers notice that while there are too many babies coming floating down the river to save them all, the chubby ones float pretty well, so they focus on pulling out the skinny ones. One of the rescuers jumps in and starts teaching the babies in the river how to swim." (Janey Skinner)

  • "Imagine a large river with a high waterfall. At the bottom of this waterfall hundreds of people are working frantically trying to save those who have fallen into the river and have fallen down the waterfall, many of them drowning. As the people along the shore are trying to rescue as many as possible one individual looks up and sees a seemingly never-ending stream of people falling down the waterfall and begins to run upstream. One of other rescuers hollers, "Where are you going? There are so many people that need help here." To which the man replied, "I'm going upstream to find out why so many people are falling into the river." Saul Alinsky, in Shelden & Macallair

  • "As you look further upstream, you notice bridges in various states of repair along the river. Some are strong, made of sturdy components. Others are weak and debilitated, with missing boards or flimsy railings. It doesn’t surprise you that most of the people falling in the river are crossing the poorly made bridges and those individuals that live near or travel across the strong bridges are protected. Of course, all of the bridges could use more reinforcement, but it’s easy to see which bridges need the most attention... In the stream parable, we know that certain groups of people are more likely to fall in the river than others. They do not fall in because of individual weakness or intrinsic flaws. Rather, we know that some people are privileged to live in communities with strong bridges, usually made of high quality materials that protect them from falling in the river and promote their safe passage across." -Erin Knight, excerpt from draft of Delaware Division of Public Health report, "Health Equity Guide for Public Health Practitioners and Partners."

Moving Upstream: A Story of Prevention from Injury Prevention Research Center is an on-line presentation with this story:

  • Story of Moving Upstream “I am standing by the shore of a swiftly flowing river and hear the cry of a drowning man. I jump into the cold waters. I fight against the strong current and force my way to the struggling man. I hold on hard and gradually pull him to shore. I lay him out on the bank and revive him with artificial respiration. Just when he begins to breathe, I hear another cry for help. I jump into the cold waters. I fight against the strong current, and swim forcefully to the struggling woman. I grab hold and gradually pull her to shore. I lift her out onto the bank beside the man and work to revive her with artificial respiration. Just when she begins to breathe, I hear another cry for help. I jump into the cold waters. Fighting again against the strong current, I force my way to the struggling man. I am getting tired, so with great effort I eventually pull him to shore. I lay him out on the bank and try to revive him with artificial respiration. Just when he begins to breathe, I hear another cry for help. Near exhaustion, it occurs to me that I'm so busy jumping in, pulling them to shore, applying artificial respiration that I have no time to see who is upstream pushing them all in....” (Adapted from a story told by Irving Zola as cited in McKinlay, John B. "A case for refocusing upstream: The political economy of illness." In Conrad and Kern, 2nd edition, 1986, The Sociology of Health and Illness: Critical Perspectives. pp. 484-498.) Quoted on Page 5
  • I like to give this classic public health primary prevention story a twist that focuses the primary prevention parable into one that is specifically perpetration prevention-oriented. Since sexual violence is not a crime or situation of the victim "falling into the river" but being "pushed into the river" I tell it that the "rescuer" goes upstream to the head of the river to figure out who is pushing the people in and why. This "rescuer" deals with the perpetrators by holding them accountable and ensuring that they receive treatment and attention to stop the harmful behavior of pushing people into the river to drown. (Alisa Klein) "Suppose you are standing next to a river, and you see someone drowning as she floats downstream. You jump into the river and pull her ashore. As soon as you've done that, you see another person in trouble, again floating downstream, and you rescue him as well. Every time you've saved one person, you see another, and another. After you've dragged another drowning body out of the river, you're thoroughly exhausted and you know you don't have the energy to save one more person, so instead you decide you must go upstream to find out what is causing these people to end up in the river. You want to address this problem at its source. You get upstream, and see a bridge. Upon careful inspection, you find that there is a well-concealed, yet sizable hole in this bridge that is causing people to fall in. What do you do? You do what makes the most sense - you work to repair the bridge. Primary prevention means "going upstream" and repairing the bridge before more people fall through this hole. Too often we just focus on the tangible aftermath of a problem. We just keep pulling people out of the river - we set up systems to support people directly affected by sexual violence. While these systems of support are crucial, we also need to cultivate complementary systems that get to the core of the violence, stopping it from ever happening in the first place. We need to become proactive, go upstream to that bridge, study it, determine what resources we need to repair it, and start doing the long and hard work of primary prevention. For sexual violence, it means examining and changing individual attitudes that lead to patterns of relating that create norms that shape the institutions in our society that allow sexual violence to thrive. Addressing these underlying factors is all the more difficult because they are intertwined with the identity of our society. Rigid gender roles, male entitlement, and glorification of disrespect play major roles in our society in the same way that the bridge is central to the culture of its nearby communities." The key thing about this version that I've found useful is the metaphor of a "well-concealed, yet sizable hole" in the bridge to represent the factors in our society that help support sexual violence and yet seem/are so commonplace. So I guess this version might be more geared toward trying to get those "big picture" factors across to folks, whereas other versions of this story - where you go upstream and find someone pushing people in - might work better for exposing factors that are at a more individual level. In my expanded version of this story, there actually is a group of privileged folks who live near the bridge (the "Bridgies") who receive a greater proportion of the toll revenue from the bridge and have a far greater knowledge of the bridge structure itself. As such, Bridgies have a strong interest in extolling the virtues of the bridge and promoting its use (which sometimes includes minimizing the danger of the hole) so as to keep their "superiority" intact. Holding the Bridgies accountable to come clean and repair the bridge then becomes a major goal. (Brad Perry, Virginia Sexual and Domestic Violence Action Alliance). Excerpted from "Moving Upstream" March 2005 Issue.
    • Our organization assigns a different duty to the rescuer, and furnishes him with some interesting "supplies." Here's our twist: When Alisa's rescuer arrives upstream he finds it is far from evident who is doing the pushing. After all, being "in the river" means the victim has already been terrorized into lifetime silence. They're not available to point out offenders. Dr. Carla Van Dam's new book proposes useful categories of offender as Groomers and Grabbers. The clumsy Grabbers get spotted and their pushing is stopped. The clever Groomers don't get spotted, and their pushing continues. Our Secondary Prevention approach is inspired by the "Van Dam Plan" and focuses on reducing that splash-count. It equips the rescuer with supplies of inconspicuous life preservers the children wear to assure survival in case they are pushed, and with foolproof single-use "magic gloves" the adults have to wear. The gloves light up when a push occurs, but they cost $300 a pair. Lacking budget, the rescuer has mostly fake ten-cent gloves which don't light up but look exactly like the ones that do. Quite a few, however, are genuine and really work. New gloves are issued every day, so the undetectable Groomers are forced to play Russian roulette with their pushing. It is such a high-stakes game for them that the Groomers use their cunning to find benign-sounding excuses for dropping-out. (Let's hope they voluntarily "drop-in" to one of Alisa's progressive treatment clinics on the way.) Magic gloves? We have 'em. But you can't just buy the ten-cent version, otherwise who would even believe in them? (David Allburn, Safe Harbor Resources)

  • For a kinesthetic activity to illustrate primary prevention,you actually acted out the river concept. Give 15 or so of the adults a colored index card that could be put on a piece of string around their neck which told them whether they were the "Upstream Bad Guy", the "Floaties" where you were "floated" down the river, the "Helpers" who were trying to save people before they got to the end of the river near the waterfall, and then the "New Thinker" who would try to go upstream to see what was going on. The rest of the audience would be "Problem Solvers" and how to act out their roles. After working for awhile with the "Helpers" [the Floaties would have to go back discretely up to the top of the river ;)] the "New Thinker" would articulate to the audience that there must be another way, and ventures out to find out what is happening. The "Helpers should talk to the group about any misgivings they may have. While going upstream the "New Thinker" would encounter "The People of the Old Paradigm" who would articulate reasons why they should help the people already in the water and not drain resources by going to the source: That is where the funding is, what about the people that are drowning, we are too overworked and stressed etc. the "New Thinker" would then look to the audience for assistance as to what good comebacks might be. Why it is important to invest in primary prevention, ways it can work in tandem with what is already happening etc., and once they answered sufficiently they People of the Old Paradigm would sit down as their reason was eliminated. Then the "New Thinker" would be able to come face to face with the "Upstream Bad Guy" or whatever label, and stop them from throwing people in the river. (Erica Staab Westmoreland, South Carolina Coalition Against Domestic Violence and Sexual Assault)