Samuel Fox

Quotes

I’m a clinical cardiologist first and I was going to be an engineer before WWII and then fell into medicine and ended up working with things like hydrodynamics of cardiac function and things like that. The interest in physical activity was that we had patients on whom we operated that I said, “Hey, these people need help retraining themselves and getting back to fitness.” We had a beautiful gym on the 14th floor of NIH and so I would take them up there and we would walk around the gym and then we’d do light weights and stretching, flexibility exercises, because they all had tight chests and so forth. We didn’t call it rehabilitation, but that’s what it was. (9)

The Heart Disease Control Program got its funding, as I understand it, from NIH much to the distress of people like Bob Berliner and others who were not keen on Framingham and some of the programs that were competitive with the Intramural Program. And I can understand that. He was a basic scientist, Bob Berliner, and I respected him greatly. But I had a clinical approach and he had a background in basic science; he was a renal physiologist and such. Anyway, when I moved to the Heart Disease Control Program shortly thereafter there was some “administrative clarification” in which we became part of the Bureau of State Services, which I greatly regretted because nobody in the academic world or the investigative world knew anything about or gave a hoot for the Bureau of State Services. Although its function was obviously very important to try to put that which came from anybody’s research into practice. (7)

But that was the beginning of my understanding of the fact that probably coronary disease could be prevented. When I got to London I read about Jerry Morris’ study. I came back with a clinical cardiologist’s idea that exercise and all that was only useful insofar as post-surgical [rehab] and maybe I had some cardiomyopathy patients that I tried to put on exercise programs. Had difficulty persuading colleagues that that was worthwhile. A safe thing to do. They weren’t really sick and fortunately nobody died. But on the idea that to have a meaningful life you should be able to do things, be self sufficient. . . that was quite different than preventive approaches. I still had acquaintance with Jerry Morris’ study.

. . . somebody came in from Cincinnati named Ralph Paffenbarger to see Jim Watt about his little program at the Institute of Occupational Health or whatever the heck the name of it was in Cincinnati, which was a Public Health Service operation, totally addressing occupational health. But Ralph had gotten somehow located there and was following up the Harvard and Penn Alumni Study. . . . But he had a couple of hours, I think, with Jim Watt or at least an hour or so and I think we went to lunch. . . . Anyway, I drove him over to the Baltimore and Ohio station in Silver Springs just as a courtesy. “Oh, I can take a cab.” I said, “No, I’d like to hear more about what you’re doing.” Because I really didn’t know that he was getting money from the Heart Institute to do his studies, and I didn’t know much about them. He was very convinced, of course, that physical activity was important. This was a kick up in my understanding and my perception of things that were important. So when I went to the Heart Disease Control Program I was convinced that we should keep looking at the physical activity thing. (14)

And on coronary care units we were working with Tom Killup and Bernie Lown and other worthies. So we had a whole gamut of things that were hot potatoes, so to speak. A lot more immediacy in trying to move those along than there was in the potential place of physical activity as a preventive approach. . . . I was a believer in the sense that I liked an active life. But that was quite separate from the preventive aspects. Jim Skinner, for instance, when he was with Cureton at Illinois had done the first analysis of triglycerides in physical activity and clearly demonstrated that he would get triglyceride lowering in physical activity, which was a major step forward. (19)

Predicting Maximal Performance

Bill Haskell was very productive and you may have read in the NY Times his commentary a year and a half, two years ago about 220 minus age a target heart rate, which obviously nobody should believe as being anything more than a first cut. But he did all the foot work on going through the six or seven studies that he distilled down and put as chart up with the age and heart rate on the vertical and age, peak heart rate achieved with bicycles in Scandinavia and with treadmills in the U.S. and elsewhere.

Anyway, . . . on the plane we were looking at that diagram that Bill put together and I was trying to jiggle the line and figure out if there was some simple sort of a formula that let us say, “This is your first cut at what maximum heart rate is likely to be for somebody of a certain age working on something that is really demanding like a bicycle or a treadmill or a ski machine or something.” And came up with the 220 minus the age. (21)

Maximal or Submaximal Testing?

So we got into trying to push treadmill testing. Bob Bruce and I went round and around. Bob and Eleanor used to travel in Europe together [to] various meetings that he was pushing for maximum. In other words, push everybody to maximum. And I tried to sell that and most cardiologist said they weren’t willing to do that even though Bob Bruce has published this thing as worthwhile. So I said, “Do you think we can learn as much or we can get a sizeable percentage of the relevant positives and not too many false negatives if we went to 85% of maximum heart rate?” Bob Bruce was off the wall.

Oh, boy, was he unhappy because he had clearly demonstrated [the variability in submaximal testing]. I have publicly on numerous occasions indicated to him that I was wrong. . . I was doing treadmill studies as part of that and I was always going to what I considered to be max. [But] how do you define it? Expired gas is much too complex . . .the idea of a plateau of expired gas is unrealistic as a clinical index. Anyway, I was convinced that the further you go the more information you get. Although you will get false positives that on angiography turn out to be innocent. But that was a real struggle . . . But we had our differences on that. He was right. And now I think everybody likes to think they go to maximum. They don’t. And perhaps they shouldn’t. We don’t know that. (22)

A Supportive Constituency

As Director of the Heart Disease Control Program, when we wanted more money we would go to Elliot Corday who was a cardiologist in Los Angeles, Cedars Sinai. . . A very worthwhile guy. But he was looked on as sort of a loose cannon by the traditional cardiological community because of some other things. Not his espousal of the Heart Disease Control Program. But he was of tremendous help to us in the coronary care effort and got big monies – six million or eight million for coronary care units and related ambulance services and things like that. And we’d go to him and Mike DeBakey and Mary Lasker and Mary Lasker had a sidekick. What’s her name? [Jesse Marmorston] The one I’m thinking of was a gal who wanted to put all men on estrogens. Anyway, they were our message carriers to Congress and to the public. And it was very easy to turn Mike DeBakey and Mary Lasker on and they were long-time comfortable contacts with Jim Shannon at NIH and other places.

The Critical Factor: Jim Watt

So we had our lines of communication well established well before I was even in Jim Watt’s office. Jim was very smart in that regard. Jim was a very important part of the Heart Disease Control Program. I think probably without his background in infectious disease epidemiology we never would have seen Framingham, never seen the Heart Disease Control Program as it became with field stations like Missouri and San Francisco or with….just block his name ….. with CDC –[the] cholesterol [standards lab]. . . Gerry Cooper. All those things, I think, if not very directly a product of the influence of Jim Watt were very closely tied to him. . . and [if not for] the charge that he gave me to get up to speed on Framingham and other things, I would have been a clinical cardiologist. Yes, these little seeds were someplace, but they needed watering and fertilizing. (23)

I didn’t tell you the mechanism of the demise of the program. My understanding and this was second hand from people like Don Chapman who became a rear admiral in charge of the Bureau of State Services, who allowed . . that one of the directors of another program similar to the Heart Disease Control Program . . . got up at the American Cancer Association meeting and complained publicly that they weren’t getting enough money in the Cancer Control Program. Now you don’t do that as a federal employee, commissioned corps, civil servant, or anybody else, as you probably well know. And this hit the papers as I understand it. I don’t remember seeing it. That this fellow named Kelly. . .was being charged by the Nixon Administration to cut back on health and welfare funding and he got all steamed up and. . .wanted to cut all the programs. But the Congress had just approved the Smoke House as we called it – smoking and health and the Kidney Program, which was supporting dialysis. Two new, highly worthwhile programs. So somebody said, “Hey, you can’t cut them. Congress just established them in the last couple of years.” So they were, I guess, sent to CDC or maybe kept in the Bureau of State Services. . . I don’t remember. But all the other programs – arthritis, metabolism, which was one program, cancer, heart, and some others, diabetes, metabolism, yeah. Anyway, [ed. he makes a cutting sound]. The Public Health Service had a real problem trying to get people relocated without essentially terminating their commissioned corps service and likewise with civil servants. Many of them, I think most of them, went with Regional Medical Programs. But that was sort of rocky for a while. (23)

Anyway, at the time of the Heart Disease Control Program [closure] thing I said to him [Senator Mathias] “What can we do about this?” He said, “I’m familiar with your program and it sounds like what you’re doing is very worthwhile, but the administration is bound and determined to economize and I don’t think there’s anything we can do.” Gordon Barrow whom you may have known, spoke to his Georgia Senators and he had a lot of pull with them. I forget who they were at that time. But he said, “Can’t do anything.” Elliot Corday, George Griffith who was in Los Angeles and a very powerful figure in everybody’s mind, he wasn’t the maverick that Elliot was sometimes considered to be. George spoke to his Senators. Elliot spoke to Mary Lasker. I mean we tried to get the guns going. NIH was no help at all at that time. Bob Berliner was Deputy Director, I think, at that time. People spoke to them, but negatives. Nobody is against anything. They don’t like to be registered as being against it. They said, “We’ll see what we can do” or something noncommittal. It didn’t go anywhere. (28)