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Lester Breslow, a pioneer in chronic disease prevention and health behavior intervention, shares insights from his professional and personal experiences

JoAna Stallworth, PhD, MPH and Jeffrey L. Lennon, PhD, MD, MPH, MSPH

JoAna Stallworth is with the Department of Medicine, University of Alabama at Birmingham. Jeffrey L. Lennon is with the College of Education, Foundation University, Dumaguete, The Philippines, and the International Technical Assistance Group, Seattle, Wash.

Correspondence: Requests for reprints should be sent to JoAna Stallworth, PhD, MPH, University of Alabama at Birmingham, Department of Medicine, Division of Geographic Medicine, BBRB 206, 1530 3rd Ave S, Birmingham, AL 35294-0022 (e-mail: stallworth{at}uab.edu).

	INTRODUCTION

TOP INTRODUCTION THE ALAMEDA COUNTY STUDY HEALTH BEHAVIOR CHANGE CHALLENGES FOR SOCIAL... References

 

Dr Lester Breslow

DR LESTER BRESLOW IS AN important voice from public health’s past and present, with

insights for the field’s future. Breslow’s exemplary career in public health has spanned more than half a century. He was involved in the pioneering of chronic disease prevention and health behavior intervention.¹ One of his most notable contributions to the field is the measurement of health. His work in the Human Population Laboratory (Alameda County Study) quantified health risk practice and lifestyle issues such as exercise, diet, sleep, smoking, and alcohol consumption and defined their relationship to mortality.^2,3

During his career, Breslow held positions as California’s state director of public health, director of the President’s Commission on the Health Needs of the Nation, president of the International Epidemiology Association, president of the American Public Health Association, president of the Association of Schools of Public Health, and professor and dean of the University of California, Los Angeles School of Public Health. He is currently a member of the Institute of Medicine of the National Academy of Sciences and recently served as chair of the Los Angeles County Public Health Commission.

Breslow’s research agenda and professional background still yield insights into the new era of health promotion and wellness.⁴ For example, the relationship of health practices to disability, as presented by Breslow and Breslow,⁵ enhances the field’s understanding of resiliency, a key component of wellness.

In the new era of health promotion, issues concerning personal responsibility vs societal responsibility,⁶ and wellness models vs risk reduction framework models,⁷ have emerged. These and other issues, along with insights from his past and current professional practice and his personal life experiences, guided our interview with him, which was conducted in 2000.

	THE ALAMEDA COUNTY STUDY

TOP INTRODUCTION THE ALAMEDA COUNTY STUDY HEALTH BEHAVIOR CHANGE CHALLENGES FOR SOCIAL... References

 
Perhaps Breslow’s greatest public health accomplishment, as suggested by others and acknowledged by himself, was the Alameda Human Population Laboratory.

"First, I must emphasize that I worked with a lot of people," Breslow said. "Nothing has been done alone. I suppose development of the Alameda County Human Population Laboratory was my greatest accomplishment. The first cohort participated in a health survey in 1965 and has followed [subsequent surveys] ever since, just finishing the fifth questionnaire. We considered health behaviors including 7 health habits and found them to be strongly associated with most [current] or subsequent morbidity and mortality. This venture grew out of 1950s efforts to measure health—physical, mental and social well-being—in accordance with the WHO [World Health Organization] definition of health. It asked questions on common health-related habits."

"Also, I was active after World War II—I served in the military—in moving chronic disease control to the forefront of public health," he added.

Breslow distinguished himself in research, academics, and public service. He is a person of few regrets. However, when asked what he would do over again if given the opportunity, he responded, "I suppose serving as a state health director. I served for 2 and a half years, from 1965 to 1968. I wish I had done more in that situation."

Public health is an everexpanding and developing field. One unfinished task in public health that Breslow would like to see accomplished "is the delineation of wellness and the public health approach to that." He elaborated, "People are now living into their 70s, 80s, and 90s and want to live a full, buoyant, enjoyable life. It’s a whole new ball game. While there is a lot of disease in this country and other parts of the world, we have progressed so far now as to envision moving towards seeking well-being. People should be able to climb mountains, listen to music, go dancing or pursue whatever different interests they have."

Much of Breslow’s work has dealt with developing the risk reduction framework. When asked how he felt about the replacement of the resiliency/wellness perspective by the risk reduction framework, he referred us to his 1999 article ‘From Disease Prevention to Health Promotion.’⁴ "Accepting the Ottawa Charter’s definition of health as a ‘resource of living’ means that health promotion is increasing such capacity," he added. "I believe that the next stage of health improvement will emphasize expanding anatomical, physiological, mental, and other resources for living—not just preventing and treating disease. We are ready to use and extend the WHO concept of health: ‘physical, mental and social well-being—not merely the absence of disease and infirmity.’ "

	HEALTH BEHAVIOR CHANGE

TOP INTRODUCTION THE ALAMEDA COUNTY STUDY HEALTH BEHAVIOR CHANGE CHALLENGES FOR SOCIAL... References

 
Throughout much of his work, an emphasis on individual initiative in health behavior change is evident. Breslow believes that an overemphasis on individual responsibility instead of societal responsibility leads to "victim blaming." "In the report on Health Needs of the Nation for Truman in 1952," he said, "we delineated the issue quite clearly. People make choices. You and I can decide each day on positive health behavior or negative [health behavior], though most [behaviors] become ingrained in us as habits. Such decisions are not made nor habits developed in a vacuum, but in a social context in which we live. If people live with smokers, smoking is more likely; if people live with exercisers, they tend to exercise. Social factors, advertising, availability, are all determinants of each individual’s choices. As public health workers, we should make it clear that people do have choices, but they exercise them mainly under social influences."

At the end of his book Health and Ways of Living,³ Breslow specifies that social action is necessary to influence health-related behavior decisions—social interventions will be more practical and efficient than individual ones. "An example of that," he said in the interview, "is the successful tobacco smoking control program in California. A great effort of volunteers, public health, and medical people was instrumental in passing legislation as an initiative. A tax of 25 cents per pack is for specific hospital, medical, and other services, with 20% for interventions encouraging people not to smoke. The program involved a very broad network: school, work, health department, state, community organizations, [and] media. Projects spreading the word in neighborhoods, as well as use of mass media, were quite effective. The whole milieu about smoking was being changed, reversing the general tolerance of it. In government offices, smoking was prohibited, in workplaces and in restaurants and bars smoking was also prohibited. So there is progress to making smoking unacceptable."

	CHALLENGES FOR SOCIAL INTERVENTIONS

TOP INTRODUCTION THE ALAMEDA COUNTY STUDY HEALTH BEHAVIOR CHANGE CHALLENGES FOR SOCIAL... References

 
In conducting social interventions, there is the potential for conflict between personal autonomy and the common good. Is it right to make laws on personal health choices when such decisions can improve the health of the whole society? Some have referred to this as "health fascism," an observation that drew laughter from Breslow. "Such laws can appropriately be passed when individual behavior is a hazard to someone else," he said. "For example, secondhand smoke kills people and causes disease. Laws may be passed to protect people who may be exposed in the workplace, such as flight attendants. Yes, it is appropriate when one’s individual behavior imposes a risk on other people."

Breslow is a person who practices what he preaches. He has learned from his own research. This is exemplified by his personal interests and hobbies. "You should know I am in my 86th year. I walk 2 and a half miles for 45 minutes 5 days a week," he said. (Three years later, aged 89, he reports still walking 5 times a week.)

"Two years ago I had a heart attack. People ask, how come? I answer, for the first 50 years of my life we didn’t know the reasons for them. I garden, raising vegetables and fruit. You should have seen the figs this morning. Also in season we have oranges, lemons, plums, peppers, tomatoes, beets, etc. I am married, have children, grandchildren, and two great-grandchildren ages 6 and 3."

His pastimes include keeping current with the public health literature and important global news. "I read mainly professional magazines such as the American Journal of Public Health, and other medical and public health journals," he said. "I recently read and disagreed with some of Tom Friedman’s The Lexus and the Olive Tree, a discussion of globalization."

Dr Lester Breslow, a pioneer in chronic disease prevention and behavioral intervention, is our model face of public health past, present, and future.

	Acknowledgments

 
Thanks to Nader Nassif for permission to use the photograph of Dr Breslow and to Chona F. Lennon for technical assistance. We are grateful to Dr Lester Breslow for his approval and for his cooperation throughout the interview.

Accepted for publication May 12, 2003.

	References

TOP INTRODUCTION THE ALAMEDA COUNTY STUDY HEALTH BEHAVIOR CHANGE CHALLENGES FOR SOCIAL... References

 
1. Breslow L. Musings on sixty years in public health. Annu Rev Public Health. 1998;19:1–15.[ISI][Medline]

2. Belloc NB, Breslow L. Relationship of physical health status and health practices. Prev Med. 1972;1:409–421.[Medline]

3. Berkman LF, Breslow L. Health and Ways of Living. New York, NY: Oxford University Press; 1983.

4. Breslow L. From disease prevention to health promotion. JAMA. 1999;281:1030–1033.[Free Full Text]

5. Breslow L, Breslow N. Health practices and disability: some evidence from Alameda County. Prev Med. 1993;22:86–95.[ISI][Medline]

6. Minkler M. Personal responsibility for health? A review of the arguments and the evidence at century’s end. Health Educ Behav.1999;26:121–140.[Abstract/Free Full Text]

7. Brown JH, Horowitz JE. Deviance and deviants: why substance use prevention programs do not work. Eval Rev.1993;17:529–555.[Abstract/Free Full Text]

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