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doi: 10.1097/01.ede.0000158800.01170.36

A Conversation With Lester Breslow

Baquet, Claudia R.

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Editors’ Note: Voices is a project of the journal to provide personal, historical and scientific perspectives on the field of epidemiology, as seen through the eyes of the field’s most senior and accomplished practitioners. Subjects are selected by the Editors. Readers are welcome to nominate candidates for Voices.

This interview was conducted 20 August 2003, at the University of California Los Angeles, School of Public Health. Lester Breslow has approved this transcript for publication.

Lester Breslow’s curriculum vitae is available with the online version of the journal at www.epidem.com.

Correspondence: Claudia Baquet, School of Medicine, University of Maryland, Suite 618, 685 West Baltimore St., Baltimore, MD 21201. E-mail: cbaquet@som.umaryland.edu.

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Lester Breslow was born 17 March 1915, in Bismarck, North Dakota. He did his undergraduate work at the University of Minnesota, where he also received the MD and MPH. After serving in the U.S. Army in World War II, Dr. Breslow took a position with the California State Department of Public Health, eventually serving as its Director. Dr. Breslow joined the faculty of the University of California at Los Angeles in 1968 as Professor of Public Health. He chaired the Department of Preventive and Social Medicine in UCLA’s Medical School and served as Dean of the UCLA School of Public Health for 8 years.

His research has explored the causes of lung cancer (including occupational factors and air pollution), and social and occupational causes of chronic diseases more generally. He has written extensively on prevention and on policies for prevention. Dr. Breslow has served as President of the American Public Health Association, the Association of Schools of Public Health, and the International Epidemiological Association. He is a member of the Institute of Medicine, National Academy of Sciences, and was founding Editor of the Annual Review of Public Health. He has received the Lasker Award, the Porter Prize, the APHA Sedgwick Medal, the IOM Lienhard Award, and other awards, and has served as consultant to dozens of state, national, and world health agencies.

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CB: Dr. Breslow, how did your career path bring you to the field of epidemiology?

LB: My first career thought began in high school when I was recovering from a severe case of stammering. I decided to become a psychiatrist, and in my junior year of medical school, I spent the summer working in the Fergus Falls Minnesota State Hospital for the Insane. That was very discouraging, because it became evident to me that we could do practically nothing at that time for severely psychotic patients, except possibly prevent them from hurting themselves or other people.

When I returned to the medical school for my senior year, I indicated my great discouragement to a good friend who was a junior faculty member. He introduced me to the new professor of public health at the medical school, Gaylord Anderson, an epidemiologist, who encouraged me to train in public health, specifically epidemiology.

CB: What do you see as the biggest difference in epidemiology when you started your career and today?

LB: In those days, epidemiology was focused on communicable diseases. There were some great epidemiologists who studied some noncommunicable diseases. We have by no means conquered the communicable diseases, and probably never will, but at least we have progressed so that people now live to ages when chronic diseases have become the major causes of illness and death.

Epidemiology nowadays has gone through what Milt Terris called the “second epidemiologic revolution,” the first focused against communicable diseases and the second against chronic diseases. Neither of these has been really completed.

CB: Who most strongly influenced your career?

LB: Gaylord Anderson had a profound influence on it. I think an even greater influence on its development was a staff member at the California State Health Department, where I worked in 1946 after returning from military service. Robert Dyer, then the Chief of the Division of Preventive Medical Services, allowed and encouraged me to enter a career in epidemiology, devoted in the beginning particularly to chronic diseases. I first wanted to develop application of epidemiology to the chronic diseases, and the State Health Director in California at that time would have none of it. As I was packing to move back to Minnesota, an old friend in the department introduced me to Bob Dyer, who said, “Dr. Breslow, do you know anything about encephalitis?” I do not think anybody knew very much about encephalitis in 1946, but I had been through a couple of epidemics, 1 in Minnesota and 1 in Okinawa in the military. “Oh, you’re just the man,” he said. I explained to him that I wanted to work on chronic diseases, not encephalitis. He said, “We have this project that we have to do. But I tell you what you can do. You have to visit your doctors and so on, but you can write me memos about the chronic diseases.” I was so confident that we would have to move into the chronic diseases that I agreed to that. That is how I got started in the California State Health Department, by writing memos to Dyer. Within 8 months, the Department had funds for cancer control from the NIH (NCI in those days).

CB: Who would you regard as some of the most important epidemiologists during your lifetime?

LB: Two of the people I would mention would be Richard Doll and John Last. I think they have had a tremendous influence on epidemiology, both in methods and in substance. Richard Doll has been a leader in the identification and documentation of cigarette smoke as a major cause of lung cancer. In recent years, he has devoted substantial energy and time to assuring that the results of that epidemiology are implemented. For example, he has been quite prominent in participating in trials that have established methods other than epidemiologic (legal methods, for example) that we need to do something about [cigarette smoking]. He has done other work, some of which I have even criticized, but I certainly think that he is one of the outstanding epidemiologists of the world and in my generation.

John Last has been much more of a leader in methodology and in standardizing epidemiology. He has made a tremendous contribution with his dictionary, and beyond that, he is a prolific writer. I regard those 2 as being outstanding.

CB: Which do you think has been your most influential paper?

LB: I think other people would be more appropriate to answer that question. However, since you asked, if I had to pick one, I would pick a paper Ann Somers and I wrote in the late 1970s that is more in public health and medical practice than epidemiology. It was published in the New England Journal of Medicine.1 Ann invited me to join her in writing this paper, although she put my name first, and she thought the time had come to specify what doctors should be doing at each stage of life—in infancy, childhood, adolescence, and so on, with regard to health promotion and preventive medicine. Paul Frame and others had done this before we did, but I like to think that it did contribute to the extent of lifetime health monitoring that is now undertaken by progressive-minded physicians.

CB: Do you have any thoughts on a paper that was underappreciated?

LB: I think a more recent paper in the Journal of the American Medical Association in the late 1990s entitled, “From Disease Prevention to Health Promotion.”2 I suggest [in the paper] that we are now entering the “third revolution” in public health and epidemiology when we must concentrate on health. People are now living through childhood, early adulthood, into middle life, and even later without the diseases that have plagued people in the past, especially in the industrialized portions of the world. Of course, we have to deal with the communicable diseases that still occur; far too many of them that can be prevented, and with the chronic diseases, even more.

I like the Ottawa Charter’s definition of health as “a resource for living.”3 It is something that we need [in order] to do whatever we want in life. For example, if you want to climb a mountain, you have to have certain competencies, including a cardiopulmonary system that will permit you to climb the mountain. We can define these resources for health. My thought is that epidemiologists have to delineate this field, just as in communicable diseases and chronic diseases, and to develop a measurement of health. To me, that constitutes the most important challenge in public health currently, as well as the greatest opportunity.

CB: Are you setting out a strategy to have other epidemiologists focus on this topic?

LB: I am trying to write and to talk about this whenever I get a chance. I have a paper coming out that will go beyond what I did in the JAMA article. I am also developing a project to suggest ways that we can begin to measure health, because there is not much attention to that matter. I hope to excite other epidemiologists, because given the likelihood of the extension of my life, which seems to be quite healthy at the moment, I think it is going to be up to other younger epidemiologists to pick up this notion.

CB: Let me ask you about how you choose and develop research questions.

LB: Well, I do it quite differently, I suppose, from other investigators. There are several ways, and I respect them all. Knowledge that one has developed or that colleagues have developed [is one way] to approach a matter methodically, determining the technical barriers to advancing knowledge through epidemiologic studies. The one that intrigues me the most and that I would advocate more epidemiologists consider using is, “what are the health problems of the people whom I want to study?” It may be people in North Dakota, where I was born, or people in Puerto Rico or in mainland U.S. or people in India or China or the Middle East—whatever population interests you and where you have a passion. In the United States and some segments of the population, I think we have to consider how to seek health itself as another health problem—how are we going to advance health, the competencies, the resources that people need to live as fully as they want—and get beyond studying only how to prevent cancer or control typhoid fever.

CB: What are your interests outside of your epidemiologic studies?

LB: My major professional activity and interest, apart from epidemiology itself, has been in applying the knowledge that we derive from epidemiology, putting that together with whatever knowledge one can accumulate about society and the forces of society that permit one to advance health. For example, our group in the California Health Department in the late 1940s carried out 2 of the original 7 cohort and longitudinal studies of cigarette smoking and lung cancer that were cited by the Surgeon General’s Report on tobacco and health. I was involved in initiating those studies, so I regard myself as having participated (in a smaller way than Richard Doll and some other people) in the development of knowledge about tobacco, cancer, and other diseases. That is epidemiology. However, I have devoted much more attention over the years to how to apply that knowledge, for example, participating in Proposition 99 in California, whereby the state added a 25-cent tax—in those days, this was substantial—to the package of cigarettes, a portion of which would be used for tobacco use control. I have also been interested in many other aspects of public health, including the relationship of public health to medical services, a very controversial area within public health.

I have a major interest in traveling. I have 3 wonderful sons, 2 of them with families. Some time ago we had a 4-generation family reunion of 1 portion of the family, headed by Norman Breslow, my eldest son, who is also in public health and epidemiology. One story about him...I was once in Tokyo, and I had a free day, so I called up my friend, the Director of the National Cancer Institute in Japan, for lunch. Before we went to lunch, he said, “I’d like to have you give a little seminar this afternoon.” I explained that I could not do that, because I was not prepared and I had no slides, nothing. He said, “Don’t worry. It’ll just be a couple of epidemiologist friends around the Cancer Institute, and we’ll have a little discussion.” Well, that sounded reasonable.

Coming back from lunch, however, he said, “I have to tell you that we had to get a bigger room [for the seminar], in fact the biggest that the hotel had. People are dropping their library work and laboratory work, and they’re coming to the lecture. They heard Breslow was here, so they’re all coming.” As we were going literally into the room, filled with a hundred people or so, he said, “I have to tell you that they thought it was Norman Breslow.”

CB: What do you feel is the greatest contribution epidemiology has made to society?

LB: I think the greatest contribution is a perfectly obvious one, of having developed some of the knowledge by which we can control major diseases and, thus, prolonging life and minimizing disease. Many people still do not realize that the average [age] is getting up to pretty close to 80 years, and half of people are dying at age 80 and beyond. Not only has that been achieved, but also we have vastly reduced the diseases and the disability that results from disease or injury. This advance in health has been in very large part the result of epidemiology having discovered the causation for many of these afflictions. We have not done it perfectly by any means, and I wish we had done more with developing the understanding of what can be done to control disease. We have not been so successful, in my opinion, with educating physicians about what can be achieved in the way of disease prevention and health promotion.

CB: What is your assessment of the current state of health of the field of epidemiology?

LB: I would say that it is in a moderate to good state of health, although not perhaps as good as some of the other aspects of medically related sciences. The funds have been steered largely to the laboratory sciences rather than to the social aspects of health science. I think one of the deficiencies is that epidemiology, like public health, has been coopted by the universities, in that they emphasize the development of disciplines and particularly the methodology of the disciplines—rather than the professions—even in some professional schools.

Epidemiology does not suffer as much as other aspects of public health because it can compete with other disciplines in the health sciences in a university. However, I think that great emphasis on methodology, rather than what we are accomplishing in the health of people, has not been good for epidemiology. It is not that I want to downgrade that, it is just that I would like a greater emphasis on dealing with the health problems of the people.

CB: What do you regard as the biggest risk to epidemiology?

LB: I suppose it is the trend in thinking of the public, the political leaders, and those who allocate funds from the Congress, and the state and local legislators in this country, that health is a matter for the doctors, and that what we need is to advance and move ahead from such things as the genome project to develop the potential laid out in medical science as it is applied to treatment of individuals. That tendency keeps public health (including, to a very considerable extent, epidemiology) from having the resources that it needs to develop. The challenge there is to educate people generally, including the medical profession and political leaders, in what we can achieve, what we have achieved with epidemiology.

CB: Do you feel that epidemiology has a role in influencing and improving public health policy?

LB: Oh, yes. I think that epidemiology and biostatistics have a role in delineating the causes of disease and in dealing with them, as well as bringing to bear what we know from epidemiology to try to understand the social surroundings in which we live. We need to devote more attention to this aspect of the problem. We have to participate in the development of policy, and I would encourage more of this, although I am afraid the universities and health departments do not encourage that. I think that is the responsibility of the discipline, not only to discover things, but to really make them useful.

CB: What are your theories about increasing interest in the field of molecular epidemiology?

LB: It is another aspect of epidemiology that ties us to developments in the medical basic sciences. We need collaboration, so linking molecular biology with epidemiology is certainly to be encouraged. A lot has been done by linkages with basic scientists, and now we have this opportunity in this crossdiscipline.

CB: What have you found to be most important for a good collaborative relationship?

LB: Well, that is a complicated question, but you really must have mutual respect on the part of the individuals seeking or entering into the collaboration if you are going to have successful collaboration. Another element is a mutuality of interest, even passion, for what you are studying, as well as competence in epidemiology, in whatever aspects of it are necessary for the particular study.

CB: What is the single most important piece of advice you would give a person just starting out in epidemiology?

LB: First, one should become familiar with the history of epidemiology; it gives you a long view of what has been done, as well as clues of what can be done in the field. Pick out a focus to begin to develop your skills and personal confidence. Do something useful in a particular field, and from there you can begin to move on. Always keep your eyes on what seem to be the really important health problems in the population that you are going to be studying. Look at the health problems in the population with which you want to work; you might have to study or to argue to find out what the health problems are.

CB: Are there any final comments?

LB: The advice that I would give to epidemiologists is to urge attention to the major health problems, particularly the study of health itself. How are we going to measure it and achieve it? How does it differ from disease control? Look where the opportunities are. In public health generally and in the bureaucracy, there are things you have to do that might not be to your liking, but they may have to be done to achieve some goals of your own.

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Claudia Baquet is Associate Professor of Epidemiology and Preventive Medicine at the University of Maryland School of Medicine. She is recognized as a leading expert on cancer and health disparities in minority and low-income populations. She has authored publications documenting health disparities in underserved communities. In 2005, she received the NIH Dr. Martin Luther King, Jr. Special Award for “Closing the Health Gap in Communities We Serve,” which exemplifies the principles of equity and justice in health care for all.

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The author thanks Bruce S. Smith of True Light Vision, LLC, for video and audio recording services.

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Figure. Lester Bresl...
Figure. Lester Bresl...
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1. Breslow L, Somers AR. The lifetime health-monitoring program. A practical approach to preventive medicine. N Engl J Med. 1977;296:601–608.

2. Breslow L. From disease prevention to health promotion. JAMA. 1999;281:1030–1033.

3. Ottawa Charter for Health Promotion, First International Conference on Health Promotion; Ottawa, Canada; November 17–21, 1986.

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© 2005 Lippincott Williams & Wilkins, Inc.

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