Speaking the language of prevention

Building on success with smoking, California’s top public health official turns state’s attention to obesity.

When Donald O. Lyman, M.D. ’68, oversees a media blitz against smoking in California, he draws upon his training in medicine, his years in public health and his knowledge of the differences between Spanish dialects. In California, you have to know whom you’re talking to: an anti-smoking ad in the dialect spoken in El Salvador won’t go over big with Mexican-Americans. And vice versa.

Lyman picked up a sensitivity to linguistics along the way as chief of the Division of Chronic Disease and Injury Control, a post that his colleagues say is California’s equivalent of surgeon general. “California has become to this nation what New York was a century ago. It’s the port of entry to immigrants,” says Lyman. “You drive down the street in LA with the windows open and smell the wonderful smells that change from block to block.” He describes the state’s 36 million residents as “a wonderful collection of well-motivated people who came here looking for a better life.” Helping to provide that life is Lyman’s mission as the state’s highest-ranking civil service physician. Under Arnold Schwarzenegger, he’s serving his fifth governor since taking the job in 1978. This year he heads a staff of 375 employees and oversees a $200 million budget.

His agency’s biggest victory has been its anti-smoking campaign, which reduced cigarette consumption in California by 64 percent between 1988 and 2003, based on cigarette sales, according to California and federal data. (During the same period, consumption fell 36 percent nationwide, excluding California.) “It’s huge,” says Lyman. A 2000 analysis in The New England Journal of Medicine found that California’s anti-smoking program resulted in 33,300 fewer deaths from heart disease between 1989 and 1997 than would otherwise have been expected.

That $1 billion program was funded by California’s Proposition 99, a 1988 law that increased the cigarette sales tax to fund the nation’s largest-ever tobacco control program. Lyman claims its success cost the tobacco industry $2.9 billion in California sales in the decade beginning in 1989, and he cheerfully reports that the industry views California as “Public Enemy Number One, with a well-funded program that works.”

How did they do it? As in all public health campaigns, from promoting seat belts to discouraging teen drinking, they did it partly by changing society’s “ethos.” They challenged the assumption that smoking is a neutral, strictly personal choice, both “from the top down,” with anti-smoking billboards and public service announcements, and also from the ground up, by approaching community groups and civic leaders. This grass-roots strategy aimed to get communities to adopt the battle against smoking as their own. The Division of Chronic Disease and Injury Control hired public health educators to visit neighborhood groups, schools, city councils and workplaces to discuss how smoking contributes to disease.

Lyman explains that although public service announcements and educational campaigns have clearly conveyed the dangers of smoking, “very few people come together and sit down and talk about smoking. …When you actually sit down and look someone in the eye and ask, ‘What can we do about this?’ you’re likely to get a response.” Billboards and other anti-smoking ads make people receptive, but “you’ve got to engage people personally. That’s the key to the program.” That process would be called “community norm change” by liberals or “social engineering” by conservatives, “but ... it’s all the same,” says Lyman. The health educators introduce a shift in perspective by explaining how tobacco companies cynically target vulnerable preteens and young teens. “The smoker is no longer portrayed as the villain,” says Lyman. “The smoker’s the victim.”

Lyman is unperturbed by Gov. Schwarzenegger’s penchant for cigars. “I worked with him when he was our chair of the Governor’s Council on Physical Fitness and Sports, and he was consistently supportive of all the ‘health stuff’ we did,” recalls Lyman. “The other council members ribbed him about the cigars, and he was appropriately sheepish in reply.”

Young people have proven the most resistant to anti-smoking efforts, and Lyman credits tobacco industry advertising with creating “the Joe Camel generation,” in which nationally one in four 18- to 25-year-olds smokes. But the end result—which is the point for a utilitarian like Lyman—is that smoking among California adults dropped from 23 percent to 17 percent between 1985 and 2002, and the California rates among teens are now among the lowest in the nation. Lyman’s department kept track of smoking rates using a series of surveys overseen by the University of California, San Diego.

The American Cancer Society’s California division, of which Lyman is the current president, reported that the state lung cancer rate dropped 14 percent from 1988 to 1997, based on the records of the state’s cancer registries. That compares to declines of 2 to 3 percent nationally, according to data collected by the National Cancer Institute. “To see the lung cancer rates go down is really quite amazing,” says Diane J. Fink, M.D., medical director of the California cancer society. “Don’s leadership has been paramount.”

His agency’s biggest failure? “We’ve been doing a miserable job on nutrition and physical activity,” he says. Like smoking, says Lyman, obesity, bad food choices and sloth all contribute to cancer and cardiovascular disease, which account for two-thirds of deaths and illnesses in the state. “We have an epidemic of obesity and a startling lack of physical activity,” says Lyman. Lyman said the adult obesity rate in the state (a body mass index of 30 or more indicates obesity) rose from 10.6 percent in 1991 to 18.9 percent in 2000, and type 2 diabetes in children is burgeoning.

Lyman says his agency is using the same “sandwich approach” (a low-fat sandwich, no doubt) that it used successfully against smoking: pairing a top-down media campaign with a foundation of grass-roots policy changes. In the policy realm, the mammoth Los Angeles school district voted in 2002 to ban soft drink sales to its 748,000 students by this year. Sensitive planning, like linking bicycle trails to subway lines, can make exercise more convenient. Messages to eat well derive in part from the state’s huge agriculture industry and its grocery store chains, which push produce with the catch phrase “five a day.”

As for Lyman himself, living a busy life that includes a third of his time on the road, he manages to eat “four or four and a half” of the five recommended daily servings of fruits and vegetables and to fit in an hour of combined aerobics and weight training five days per week. He and his wife, Elisabeth Blakeslee Hall Lyman (who also works in public health, as California’s assistant administrator for health services for children), both have centuries-old ties to Connecticut, including to Connecticut’s well-known Lyman Orchards. Elisabeth spent her childhood in South Hadley, Mass., down the street from the Giamattis, whose son grew up to be president of Yale. Despite Yankee roots, the Lymans and their two children consider themselves Californians.

Lyman finds inspiration by viewing his job as the promotion of social justice. He is fond of an aphorism from the Talmud that he remembers hearing in a speech by former Yale President A. Bartlett Giamatti: “You are not required to complete the work, but neither are you free to desist from it.”

—Cathy Shufro

Familiar Faces

For another public health trailblazer, a tobacco control milestone in the Bay State

Howard K. Koh, M.D. ’77, M.P.H., is another Yale medical alumnus who has won a major battle in the tobacco wars as a top state health official. When asked to name the most memorable moment in his five-and-a-half-year stint as Massachusetts commissioner of public health, Koh barely hesitates. “I’ll never forget pulling down the last tobacco billboard in Massachusetts with the attorney general, Tom Reilly,” Koh says. “That was a very public, concrete example of how much progress we had made.”

Koh’s experience as a clinician (he’s board-certified in internal medicine, hematology, medical oncology and dermatology) inspired him to join Massachusetts’ fledgling anti-tobacco campaign in 1992 as a volunteer for the American Cancer Society and the Massachusetts Coalition for a Healthy Future. “I saw for myself what happens when prevention isn’t addressed or is overlooked, particularly with respect to cancer,” he says. During his watch as commissioner, he saw the state’s aggressive efforts pay off: Massachusetts reported the fastest decline in cigarette smoking in the nation—adult cigarette consumption dropped 4 percent per year while most states saw a 1 percent annual decline. “People said the industry was too strong and the addiction was too strong, and it was impossible to make a difference,” Koh says. “We showed that we could change the social norm and prevent addiction, especially for kids.”

For Koh, who left his post in January 2003 to become professor and associate dean for public health practice at the Harvard School of Public Health, the victories in the tobacco wars are part of a larger legacy. “Just before I stepped down, a national report ranked Massachusetts as the third healthiest state in the country,” Koh recalls. “We had risen from number 10. It was a tremendous honor to be commissioner and see that level of progress being made.”

However, the events of September 11, 2001, presented Koh and other state public health officials with an unexpected and daunting set of challenges; foremost among his goals at Harvard is to prepare students to grapple with bioterrorism and other 21st-century hazards. “The essence of public health is protecting people from threats and preventing suffering,” he says. “In the post-9/11 age, public health has been broadened dramatically in its scope, and we have a critical function.”

Accomplishment and a dedication to public service run in Koh’s family, along with strong ties to Yale. Koh’s brother, Harold H. Koh, J.D., a renowned expert on human rights, was recently named dean of the law school, where his sister, Jean Koh Peters, J.D., is a clinical professor. Koh’s mother, Hesung Chun Koh, Ph.D., one of the world’s leading East Asian scholars, retains an emeritus appointment at Yale. She and her late husband, Kwang Lim Koh, Ph.D., a lawyer and democracy activist, founded in 1952 what is now known as the East Rock Institute, the oldest Korean cultural institute in the United States. (Howard and Harold Koh and their parents have been named to the K100, a list of 100 leading Koreans and Korean-Americans in the first century of Korean immigration to the United States.) Koh says his parents were an inspiration to all of their children. “Both of them viewed life in a very broad, societal way, if not a global way,” he says. “When people ask where this commitment to serve came from, I tell them—it’s in my blood.”

For his Boston-area neighbors, though, one honor among the many listed on Koh’s CV surely arouses the greatest envy. After being named a “Medical All-Star” by the Boston Red Sox for his work on melanoma, Koh, with his wife and three children standing by, threw the first pitch in a game at Fenway Park last May. “That,” Koh says, “was a magical public health experience.”

—Peter Farley

Roaming the world’s hot spots, ensuring that care reaches those who need it

Almost two decades after completing his residency in internal medicine at Yale, Michael V. Viola, M.D., HS ’66, was doing the kinds of things that serious-minded doctors do: treating patients, teaching students, heading the cancer center at the State University of New York at Stony Brook. But then something happened to alter his sure-footed career path.

While he was at Stony Brook in the early 1980s, a large influx of Salvadorans and Guatemalans arrived to escape homelands rocked by civil wars. “It was an extraordinarily unfortunate situation,” recalls Viola, who received his medical degree from McGill in 1964. “Most of them were illegal, and they had no health care. They weren’t designated as refugees escaping an oppressive government, because the United States was supporting their governments.”

Viola started collecting and sending medicine to villages in El Salvador. As that effort grew, he was joined by other doctors, and a small nongovernment relief organization was born. The group crystallized into Medicine for Peace, with Viola as its founder and director. He continues to direct the group from his home in the Washington area.

Today, Medicine for Peace, an all-volunteer organization run by a five-member executive board, has about 50 affiliated physicians and nurses from around the country. During and after the first Gulf War, members of the group spent five years in Iraq, filming the destruction, teaching Iraqi physicians, studying children’s nutritional needs and delivering medicine. In 1993, members helped negotiate the release of American oil executive Ken Beaty, who was arrested by Iraqis after he strayed across the border from Kuwait. The group’s involvement in the rescue put an end to their efforts in Iraq.

“Once that happened, the Iraqis never quite looked at us the same way again,” Viola said. “We’d done a lot of work with children, so they kind of trusted us. But once we were critical of their government, and it looked like we were working with the U.S. government, things changed, and we were kicked out in 1995.”

While Medicine for Peace maintains a presence in Haiti and Bosnia, its involvement in the current war in Iraq has been minimal because of the danger and restricted access. “There’s not much we can do,” Viola said. “We were told we need to have armed escorts at all times. We can’t operate like that.” The group hopes to send a team to Baghdad “to locate a large group of Iraqi children we brought to the U.S. for surgery in the 1990s. We hope they have survived all of the violence.”

Unlike larger, better-known relief organizations, such as Doctors without Borders, Medicine for Peace (www.medpeace.org) won’t take government funding (it relies on private donations) and will criticize U.S. policy. “We’re smaller and more freewheeling,” Viola said. “We tend to go to controversial places and take controversial stands.” But that renegade approach has risks. Noting that by the end of 2003, 57 relief and diplomatic workers had been killed since the current Iraq war began in March 2003, Viola said, “Humanitarian workers used to be protected, but the nature of war has changed. Now civilians are targeted. If belligerents kill civilians, they certainly don’t mind killing relief workers.” In August a bomb at United Nations headquarters in Baghdad killed 17 people.

Still, despite the danger, Viola, who runs the U.S. Department of Energy’s Medical Sciences Division, spends as much time as possible working for Medicine for Peace. “I’m not saying you get an enormous reward. There’s nothing rewarding about mass graves or large numbers of children dying of starvation, but you realize you’re having an impact in some small way.”

—Jennifer Kaylin


			Originally published in Yale Medicine, Spring 2004. Copyright © 2004 Yale University School of Medicine. All rights reserved.