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Speaking the language of prevention

Yale Medicine Magazine, 2004 - Spring


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 Medicinefound 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.”

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