History

The Stanford Prevention Research Center owes its existence to a mixture of vision and serendipity. The vision was that of Dr. John W. Farquhar, who came to Stanford in 1962 to specialize in the field of lipid metabolism, with special reference to diabetes. He was struck by the extent to which overweight, diabetic patients in hospital-based studies failed to follow through with what they had learned after they went home. A sabbatical in London in 1968 and 1969, studying with some of the world’s leaders in public health, confirmed his conviction that in order to truly motivate a population to make and maintain change, health education must occur outside the medical setting, reaching people in their communities.

Back at Stanford in 1969, Dr. Farquhar found the climate was becoming more attuned to his way of thinking. Faculty members were emerging from their ivory towers to become more involved with the wider community. Dr. Farquhar founded the Stanford chapter of SIPI: Scientists’ Institute for Public Information.

This organization encouraged scientists to use their expertise both to educate the public and to impact public policy and, as Dr. Farquhar says now, "got me going on the public service idea." He also took part in one of the University’s own innovative programs, the Stanford Workshops on Political and Social Issues.

In his workshop, which was open to Stanford undergraduates, Dr. Farquhar addressed the societal pressures behind the epidemic of heart disease. One of the undergraduates who took this workshop was Stephen Fortmann, who some 30 years later was to succeed Dr. Farquhar as Director of the SPRC. At the time he was a pre-med student intrigued by the pervasive pressure to smoke, and arranged to work with Dr. Farquhar over the summer pursuing one of the ideas that had come up in the workshop–specifically, the attitudes of the media on smoking. The results of this research were bleak and confirmed Dr. Farquhar’s growing conviction that a new approach was needed, one that harnessed the media to activate people in their communities, and bring them health messages in their own environment.

While Fortmann went off to medical school, Dr. Farquhar began to look for ways to put his ideas into practice. By chance, he had recently become acquainted with Henry Breitrose, who ran the graduate documentary film program in Stanford’s Department of Communication, just across the street from the Medical School. Dr. Farquhar walked over to find out what it would take to produce a film.

By chance, while Dr. Farquhar was explaining his mission, Breitrose’s colleague Nathan Maccoby stuck his head around the door. A senior researcher in the Institute for Communication Research, Dr. Maccoby was an expert in survey design and implementation, particularly with reference to health.

As Dr. Maccoby recalled later, Dr. Farquhar explained how heart disease had replaced infectious diseases as the principal killer–and how it could be solved, "if we can get people to change their behavior, and live in a more healthy fashion–for example, through the use of films that could be used to activate community groups."

As Maccoby recalled, "I was very interested, and very excited, because I could see all the possibilities of putting to work everything I'd ever worked on. But I said to Jack, ‘I’m afraid it's going to be a lot more complicated than that.’ And that was the understatement of the century."

It was in fact the beginning of a professional relationship that was to last until Maccoby’s death in 1992, as the two became co-principal investigators of the new Stanford Heart Disease Prevention Program, the forerunner and underpinning of the Stanford Prevention Research Center.

The first step for the new partnership was to bring in Peter Wood–a British-born, marathon-running lipid chemist in the Department of Medicine–and start writing proposals, with the help of a post-doctoral fellow in endocrinology, Michael Stern. There were two requests for proposals in the offing, both emanating from the National Heart, Lung and Blood Institute. One sought a dozen Lipid Research Clinics, collaborating on a massive cholesterol-lowering study. The other request was more vague, specifying only that the proposals involve research in atherosclerosis. The proposal-writing team used this opportunity to develop their ideas for a community-based public education project, which was to become the Three Community Study. As Dr. Farquhar recalls, "Ours was the only proposal that had a public education focus. We were always a fish out of water."

Applying for two grants was a stretch, but the group thought that if they didn’t get one grant, at least they would get the other.

They got both.

This triggered a major recruiting drive along the interdisciplinary lines that were to characterize the Center for the next decades. One notable hire was that of William Haskell, an exercise physiologist who was to become a key part of the team, and is now Deputy Director of the Center. Another was Janet Alexander, an instructor from the Communication Department who, until her early death in 1981, was the main architect of the public education component of the group’s community studies. Altogether, members of several Stanford departments were brought in: biostatisticians, behavioral specialists, and members of the School of Education. The team was supplemented by media professionals from the outside world: writers, designers, film makers.

First Steps

The Lipid Research Clinic staff settled down on Welch Road to undertake its long-term cholesterol-lowering study and its own groundbreaking research into many aspects of the effects of diet and exercise on cholesterol, particularly HDL. In fact it was Dr. Wood’s work on HDL and exercise that spawned so much subsequent research in that field. Meanwhile, the community studies group chose the towns of Gilroy and Watsonville (plus Tracy as a control) for their multi-year Three Community Study, whose goal was to determine whether a media campaign–with or without supplementary instruction for high risk individuals–could produce measurable risk reduction in a free-living population.

Samples of the population in all three towns were selected at random for interviews and physiological surveys before, during and after the media campaign, which was intense, with dozens of public service announcements, hours of television programming, weekly newspaper columns, and a plethora of direct mail. For the substantial Hispanic population of Gilroy and Watsonville, culturally appropriate materials were developed, including several radio soap operas ("novellas") and a cookbook advocating a traditional Mexican diet.

This study produced gratifying results. Compared to the control, residents of the treatment communities increased their knowledge; made behavioral changes, particularly in smoking and diet; and improved in physiological measures such as blood cholesterol and blood pressure. Initially, Watsonville, which benefited from intensive instruction in addition to the media effort, showed stronger effects. However, Gilroy caught up, demonstrating that a good media campaign could be effective without face-to-face instruction. These results rocketed the Stanford Heart Disease Prevention Program into the global spotlight, spawning similar studies in a number of other countries.

The results also encouraged the group to embark on the twenty-year Five City Project, beginning in 1978, for which Monterey and Salinas were chosen as education communities, with Modesto, San Luis Obispo and Santa Maria as controls. This study involved much the same core of behavioral scientists, media experts and Stanford physicians as the earlier program (with the addition of Dr. Stephen Fortmann, now returned from his training as an internist), but differed in several respects, including these:

• The education campaign ran for six years, and was aimed at the entire population, including teenagers, rather than just a sample; It involved far more community organization, partly orchestrated from Stanford and partly generated in the field;
• It included follow-up of mortality and morbidity in addition to measurement of changes in risk factor levels.
• While this study produced many significant results that replicated the positive findings of the earlier "Three Community Study," it had another major benefit: it generated a pool of expertise at Stanford in the field of health promotion and community development, which pointed the way to the next stage of development.

Broadening the Base

The 1980s saw the group begin to advance (and evolve) on many fronts.

• In 1983, it launched Stanford University’s internal Health Improvement Program, which has since expanded its interests beyond the health of Stanford’s own employees to the development of innovative programs for other worksites.
• In 1984, the group acquired its present name.
• In 1985, in keeping with its increasing interest in international health, SPRC became a Collaborating Center for Chronic Disease Prevention for the World Health Organization.
• Physically, by 1986 almost everyone was housed at one end or another of Welch Road, rather than being scattered throughout the campus.
• Using the expertise generated during the Five City Project, the Center established the Health Promotion Resource Center (HPRC), through which the Stanford group reached out to share its expertise with communities and organizations concerned with a variety of preventable health problems.
• The new Distribution Center of the HPRC began to tap an enthusiastic market for its health promotion materials, and for "how to" materials developed by the HPRC for health professionals and community organizers. To date, more than 9,000 sales have been consummated in the U.S. and other countries, comprising over a million and a half items.
• In addition to its programs concerning reduction of cardiovascular risk (with particular emphasis on smoking), the Center began to address questions of aging, adolescent health, complementary and alternative medicine, worksite health, public health advocacy, substance abuse, cancer, and the social and cultural determinants of health.
• The Lipid Research group consolidated its reputation as one of the country’s most innovative in its research on the relationship between exercise, diet, obesity, lipids, and health in people of different genders, ages and states of health. Research conducted by SPRC investigators on the health benefits of exercise significantly contributed to the current national guidelines promoting regular exercise as a key component of a healthy lifestyle. Much of this research focused on how frequent exercise improves various cardiovascular risk factors and contributes to "successful aging."
• SPRC investigators became deeply involved in issues of women's health, taking a leading role in the Women's Health Initiative and participating in other large multi-center studies, particularly those concerned with the effects of hormone replacement therapy, diet, and/or other preventive therapies on heart disease, cancer, and osteoporosis.

Here is a summary of "firsts":

• In the 1960s, Dr. Farquhar established one of the first clinics in the country to focus on the role of exercise, nutrition, and cholesterol lowering in preventing heart disease in patients (a clinic that continues today and is still unusual in its emphasis on lifestyle and prevention). In the 1980s, this experience was used in the first U.S. research study, led by Dr. Haskell, to show that a combination of diet and exercise with cholesterol-lowering medications could halt or reverse the build-up of plaque in the coronary arteries.
• In 1968, Dr. Farquhar and his colleague Gerald Reaven discovered that resistance to the action of insulin is the principal physiological characteristic of type 2 diabetes mellitus (formerly called "adult onset" diabetes before the obesity epidemic lead to the development of this disorder in children and adolescents).
• The Coronary Primary Prevention Trial, begun in 1971 at Stanford and eleven other Centers in the US and Canada, was the first to establish the effectiveness of cholesterol lowering in preventing heart disease. Stanford’s Lipid Research Clinic continues to provide advanced analysis of cardiovascular disease risk for patients at Stanford and to support SPRC research.
• It was Dr. Peter Wood of the Lipid Research Program who first established the link between exercise and levels of HDL.
• In the 1980s, SPRC investigators pioneered studies on the effectiveness of nicotine replacement in treating nicotine addiction, and in 1999 started the first study of nicotine replacement for smoking cessation with adolescents.
• SPRC investigators pioneered the development of school-based programs for preventing the development of heart disease and obesity in childhood and adolescence, and today continues to have one of the largest research programs on youth health promotion in the country. In the early 1990s, Drs. Killen and Robinson conducted the first clinical trial testing methods for preventing eating disorders in adolescents.
• In 1993, Dr. Haskell and his colleagues in SPRC and the cardiology division at Stanford demonstrated that aggressive lifestyle and drug therapy decreases heart attack rates and slowed the progression of atherosclerosis in the coronary arteries.
• In 1993, Drs. Killen and Robinson conducted the first clinical trial testing methods for preventing eating disorders in adolescents.
• In 1999, Dr. Robinson reported the first experimental demonstration that limiting children's television use prevents excessive weight gain.
• The SPRC has led in studying the role of social and cultural determinants of health, particularly in medically underserved and ethnic minority populations. Through a program in the Stanford Medical School, this research effort is also helping to increase diversity in medicine through the mentoring of economically disadvantaged high school students in California.

All of which undoubtedly represents rather more than Dr. Farquhar envisioned in the late ‘60s when he asked for advice on making a film.

[This history was written by Prudence E. Breitrose based on information provided by Drs. Farquhar, Fortmann, and Haskell, along with her own memories of a two-decade association with the SPRC as the principal writer of health education materials.]