Jeremiah Stamler

Quotes

I don’t think one can overestimate the catalytic role of certain key individuals who, by whatever circumstances, became leaders, including leaders of the National Heart Institute and of the American Heart Association.

Political philosophy and career choice

Among those I grew up with, particularly some of the left-wing people I was exposed to in the circle of friends in the Columbia University atmosphere of those years […] it was almost axiomatic that societal factors markedly influenced what happens to people, including their health. You don’t have to be a big genius to pick that up in that atmosphere during those years.

Zero correlations

In typical Keys fashion, he said, “if the intra-individual variation is greater that the inter- then you can’t predict without multiple measurements.” […] Thank God for CVD epidemiology because all of it rests on the fact that the individual [e.g. pressure and cholesterol variation] is more stable than the group and, therefore, even one measurement is highly predictive.

Amateur Epidemiologists

All of the people who became distinguished, senior, famous, whatever word you want to use, that handful of people in cardiovascular epidemiology were all self-trained. None ever did anything in the way of formal training in epidemiology, even in biostatistics. , , , all self-taught or helped by good consultants. Stop and think, Fred Epstein, Ancel Keys, one of the most senior, Henry Taylor, physiologist, Henry Blackburn, clinician. You go through the whole list.[ed. Kannel said,” not so;” he and Dawber, in their spare time, got an MPH at Harvard in the early years of Framingham.]

Of the professional epidemiologists ‘practically none of them ever evolved into anything meaningful [in chronic diseases].’ ‘And it was Tommy Francis at Michigan who recruited Epstein to organize the Tecumseh Study. He made the transition through Fred.’

Fixed Attitudes

[for example] ‘…. [Donald] Reid never changed his mind that anything but smoking was important.’

[ed. Ancel Keys never changed his mind about the lack of significant effect of dietary cholesterol, though he found its small and significant group effect. Similarly, he discounted the range of obesity among working populations as influential in CHD risk.]

[And Jerry Morris may never have changed his mind that anything other than physical activity was really important.The British are skeptical about anything relating cholesterol to diet or atherosclerosis.]

Arden House Conference

Jerry describes the Arden House as follows: ‘The famous Arden House Conference followed the 1957 publication of the first cohort data on risk factors. It was held in the Harriman estate on a hill overlooking the Hudson. A gorgeous forested hill, a typical railroad estate of the late 19th Century and early 20th Century which even the Harrimans couldn’t maintain and they gave it to charity. It was a long meeting. All the epidemiologists working were invited and Jim Watt cleverly selected younger people who had famous senior chiefs wanting to get both the chiefs and their protégés into the act. Very smart to get all these key people in cardiology and also to get young people involved. I learned from some of the discussions one of the big issues was should we at this meeting be exchanging forms or would our work be preempted and something be stolen from us if we discussed common tools?

The Arden House is where Jim Watt brought academic epidemiologists whose work had been infectious disease and quietly told them: ‘After the war there ain’t going to be much for you guys to do in the present scene if you stick with infectious disease. You guys have got to get interested in chronic disease.’ One of them from Columbia U. showed slides on the variation of blood pressure within individuals and said: ‘you can’t correlate that variable to anything. It is too unstable.’

Zero Correlations

Ancel had already put into his paper in Voeding that ‘if Intra-individual variability is greater than inter-individual, then you can’t predict without multiple measurements.’ It wasn’t greater; even though there was a lot of intra, it was less than inter-. Thank God, because all of cardiovascular epidemiology rests on the fact that the individual is more stable than the group and therefore even one measurement is highly predictive.

Makarska Conference, September 1968.

With the Ahren’s Committee Report recommending against the Diet-Heart Pilot Trial, NIH financing of preventive trials hit a low. There was nothing on the [NIH] agenda. Ancel Keys, Paul White, Jerry Stamler, Richard Remington, and Henry Talyor organized a special conference at the site of the Seven Countries 10-year survey in Dalmatia. Bethesda came up with the idea of using public law 480 funds, and many experts were invited: Jerry Green as head of the extramural program at the Heart Institute, Tom Chalmers, an expert in clinical trials, and so on. (List attendees) The conference addressed salient issues of testing of primary and secondary prevention in coronary disease.

[ed. People were looking at cholesterol as an independent variable and also as one dependent on associations with lifestyle. They were not looking at it in regard to blood pressure. Stamler said that if dietary factors are influencing the one then some factors in the environment must be influencing the other.]

Observation vs. Experiment

But I think you cannot separate the evolution of trial science and population observational science, because the heart of the trials in many respects came from epidemiological thinking, epidemiological people and epidemiological methods though some of it came from clinical medicine relating to drugs. For a practical public health point of view, it doesn’t matter. The DASH Diet is what is needed and it is very similar to the diet for lowering cholesterol. So the two risk factors can be knocked into one. All you have to do is organize the societal factors. That’s all.

National Diet-Heart Study.

[ed. Jerry Stamler claims credit for starting the National Diet-Heart Study by approaching Irvine Page at a Princeton conference on MER29, a cholesterol-lowering drug. Page was probably the most important person politically in cardiovascular disease at that time. Jerry agreed to ‘go down the path together’ with Irvine Page because, as he said, ‘I had no alternative.’ Jerry tells the story further:] ‘And [ the committee] decided to do a pilot study about which I had severe misgivings. . Ancel and I once walked the streets of New York all night because Ancel wanted to quit the study. I talked him out of quitting. He was furious with some of the proposals . . . . I said, ‘Ancel, as long as there is a group feeding a diet of the type we favor and not a diet of 40% fat with a lot of polyunsaturates, we should not walk out.’ ‘We kept that diet, it was the B Diet of the National Heart Study.’ described by some as ‘the Jerrymandered Study,’ that is, Jerry Stamler, Jerry Green, and Jerry Cornfield.’

Heart Disease Control Program: Liquidation.

They were liquidated with the stroke of a pen by Haldeman and Erhlichman for Nixon. Two Christian Scientists! Some day that story needs to be written. But these programs were liquidated. I think they were told, within 30 or 60 days, to close down. Sam Fox was beside himself to preserve the files and not let them get destroyed. I don’t know whether he was successful. The public rationale was saving money.

Cardiological Statesmanship

[Top people in cardiology had a public health view and also the capability of statesmanship and leadership. Stamler says:] ‘Over the years I think one can say politely, more or less, that the likes of Paul Dudley White, Louis Katz, or Howard Sprague, don’t grow on trees. I don’t think it’s just a bias of my stage of life. The kind of cooperation that existed between the [early] directors of NHLBI and these people in the American Heart Association, well, one has long periods in which nothing like that has [since[ been achieved. In those days, in NIH, AHA, and CDC, you had magnificent, carefully cultivated, carefully thought out, carefully worked out people and plans. For some time [more recently] we have leadership problem in that regard. We work in the footsteps of those people many years later.

The Population Strategy

[ed. Stamler speaks of the important intellectual development of the population-wide approach, not just in regard to cardiovascular disease, but human disease generally, and he credits Geoff Rose.]

I think Geoffrey Rose deserves a tremendous amount of credit for taking a germ of an idea that was there, never elaborated and never fully expressed, never 100%. Did he go to work on it. He wrote the papers and the whole book.

[ed. Later key developments conceptually, where Stamler credits himself, were the ideas of:] ‘low risk, the concept that optimal blood pressure can be established and kept that way, that there is no cure and that it’s not genetics and mechanisms and it’s not aging, it’s an abnormal process reflecting societal issues.’

The Joint Commission Report.

Mary Lasker convinced Lyndon Johnson to set up a Joint Commission on Heart Disease, Cancer and Stroke to produce the best timely recommendations based on present knowledge, with Irving Wright of New York in charge. They had a second committee to deal with the possibly over-enthusiastic first report of Stamler et al and to recommend changes in it. The new committee was headed by Lew Kuller and, in fact, affirmed everything the Stamler report had said and even made it more forceful. Only the pediatricians did not accept the report because of its nutritional recommendations for young people.

Diet-Heart Testimony

[ed. In the testimony of Jerry Stamler and Bob Levy before the Senate Select Committee on Nutrition and Human Needs under Sen. McGovern, Bob Dole said something like this in front of the Committee, in Stamler’s words]: “I came here very skeptical. I regarded it as some kind of liberal boondoggle. The more I read the documents the more I talked to the staff, the more I became impressed.”

According to Stamler: “Senator Percy of Illinois almost caved under pressure from agriculture, but Dole never caved. Dole was interviewed the next day after Bob Levy and I testified before the Committee in a ridiculous side show. He was asked by a reporter: ‘What are your farmers going to say about these recommendations?’ And Dole was brilliant, responding like this,

‘First of all, our farmers, like other Americans, are experiencing a lot of heart attacks and they would like to know what to do about this. And second of all, our farmers are very capable people. If you give them sound advice as to what to grow in terms of better health, they will produce what is needed.’ He gave the guy a very interesting lesson. He wasn’t kicked around by wise-asses from the press or anyone else. But Senator Percy backed off; Dole went further than Percy.

Kennedy once had Percy visit him and the President, who was always brief, said “What does he want?” Kennedy’s secretary pointed to the chair that Kennedy was sitting in and said, “He wants to sit in that chair, he wants to be President.” That was Percy.”

NIH and AHA:

Jerry expressed disappointment that the 50th anniversary of the American Heart going public and the National Heart Institute of NIH were celebrated separately in 1998, not together.

The Burden of CHD in 1950s

[ed. A paper by Stamler on mortality data was his first epidemiological paper and he had been asked to write it, with Moriyama, as a representative of the cardiovascular research community. Jerry had just begun in January 1948 to work with Katz on hypertension and atherosclerosis. He indicates that at the time of this paper, about 1954-55, he got interested in epidemiology.]

[Already there was experimental work going on and intellectual interest in blood pressure, salt, diet, and atherosclerosis and he got focused on why the male/female differences existed and started studying estrogens, a question still very relevant with the results of the Women’s’ Health Study. There is the story about what Louis Katz said when they appointed Jim Watt, an infectious and diarrheal disease epidemiologist, as the second head of the National Heart Institute, “What are they doing appointing a “crap” doctor head of the Heart Institute? Watt clearly set about not only to establish epidemiology as an integral part of the National Heart Institute program agenda and budget, but to enlist cardiological leaders in Chicago, New York and Boston to collaborate on development of research policy.]

Mary Lasker and Public Policy

The critical political force in the stimulation and creation of the Institute was Mary Lasker, using the Lasker Foundation money from her wealthy deceased husband, money from an advertising empire and some of it, ironically, from the advertising of tobacco. Life is full of peculiar contradictions and quirks. Mary Lasker very cleverly decided to use that money and that foundation differently from many foundations, not primarily to give researchers grants, but to compound it, if you will, to use it for political lobbying purposes, to bring into being government agencies that would give much more money ultimately for research than any of the foundations could do. But she also set up all kinds of organizations like a National Health Education Committee which produced the first report on risk factors, a statement for physicians called “Heart Attacks and Strokes.”

That was Mary Lasker and this was before American Heart said a word. American Heart said it’s first word very gingerly about smoking. The mogul from RCA, David Sarnoff, was President when they issued their first statement. And he did everything possible to slow it down and combat that statement. That first statement wasn’t until 1959 and it wasn’t until ’60 or ’61 with the landmark statement by Irvine Page that the American Heart said anything. That took a lot of doing politically but by then there was already an accumulation of evidence, animal, experimental, clinical, although not a lot, some epidemiological data on diet.

Intellectual Nodal Points

[ed. Stamler refers to intellectual nodal points and one of these is Ancel Keys’ Mt. Sinai Hospital address where his ecologic analysis, a graph showing the curve of mortality and total fat in the diet was published and later violently attacked. He speculates how Ancel, with his background, got the bright idea that coronary disease was going to be a problem and worth a career of research effort.]

[Jerry attributes his own interest to being an avid reader in medical school and to stimulation of his interest in atherosclerosis by a professor of pathology. This was a review of a number of papers on cholesterol and fat and atherosclerosis geographic pathology and apparently told the story of the physicians who went to the colonies and made these observations, so this article would be very important to find. And he also refers to a review by Wilhelm Raab along the same line. He describes two other reviews, one by Weinhouse and one by Hirsch. All of these were pre-WWII. He also refers to a review by Huper on experimental atherosclerosis.]

[He speaks of the problem of separating out hypertension from atherosclerosis as separate processes. He says that Ancel’s article on the sentimental journey mentions the early work of Delangen and others. The name of that article is Naples to Seven Countries, A Sentimental Journey.]

[By the late 19th and early 20th Century all the basic questions were there and Stamler attributes much importance to the development of our field to the pathologists in the defining of what is atherosclerosis. Pathology is important because as Stamler says, “Once you have the definition of that lesion, many things can be done, ranging from observing that it’s common in some countries but not common in the colonies and then trying to produce it in animals.” Anichikov identifying that it was cholesterol and lipid from the diet was the beginning of everything.]

[Katz and Stamler studied chickens because they were omnivorous and there was great criticism of the rabbit studies because they are herbivorous and stated that feeding experiments in rabbits were irrelevant and meaningless to the human condition. Stamler attributes the clinical work after the pathological to the coming of the electrocardiogram because it demonstrated that people could survive heart attacks and they could study the disease in the living. Then they begin to find it more in men than women, diabetics, hypertensives, hypercholesterolemics, etc. He gives credit to White and Gertler for attributing young coronary disease to high cholesterol.]

[In Stamler’s book on experimental atherosclerosis he reviewed the epidemiology and in the monograph he has graphs of those war-time findings which included WWI and the starvation afterward. Stamler attributes the flurry of activity after the Arden House Conference to the charge by Jim Watt to go out and think and work in this area.]

It is unclear if it was Frank Yeager or Jim Watt who said this to him

You know if you’re really interested (in epidemiology) there are 4 stages. The first stage is to do some work on the mortality data. See what you can find of interest in the mortality data. The second stage is find yourself a population or two and collect a cross-section of data in the population and then find yourself at the same time, or close thereto. . populations you can do prospectively. And the third and fourth stages get involved in intervention studies.” [ed. That laid out my whole life, says Stamler. And we agreed that day at lunch, Louie Katz reluctantly, that I could spend 20% of my time on epidemiology.]

[ed. He attributes being invited to the Arden House Conference as the most important influence in that it took hold in his early and general interest in societal factors and the way people live having a lot to do with health. He told:] Ideas and things I picked up in the social atmosphere of Columbia and New York in the ‘30s. It was almost axiomatic around the Columbia atmosphere those years that societal factors markedly influenced what happens to people, including their health. You don’t have to be a big genius to pick that up in that atmosphere during those years.

[Stamler discusses the early development of the field when Darwin Labarthe asks him this question: “How do you see the convergence of the work among individuals into something that formed what we would call a field, a movement, a body of scientists?”]

There were always public health people looking at mortality trends and trying to make sense out of them. Especially as the infectious disease mortality trends plummeted. Then there were always isolated people in fields like anthropology and psychology interested in human phenomena and only peripherally in disease. Then there were those who connected not only experimental, but clinical, geographic, pathologic, even before epidemiology indicating there is something here in the way human beings are living and this particular disease. [ed. The crucial catalytic role of a few key leaders.]

[ed. Stamler goes on to say a very important conceptual issue was the recognition of separation between atherosclerosis and aging. The arguments were, some people reach older age and never get it, some people get it very young. There was the already well-known idea that there were different rates across the world. Since human aging is not that different anywhere, as far as we know about it, consequently aging couldn’t be the explanations.]

Jerry Stamler: The intellectual prerequisite for an approach to atherosclerosis as a disease related to lifestyle was the recognition that this is not just ‘normal’ aging. [ed. Stamler says he verbalized this in a long polemic in his book with Katz.]

A crucial development nationally and internationally came from Bethesda and the leadership there and the alliance they made with the statesmen in cardiology. …. the role of Frank Yeager and Jim Watt wanting to develop program grants on atherosclerosis.

[ed. Stamler discussed how Bethesda broadened the net to include others than the grand patrons of cardiology with the following story:]

Louie Katz’ group was invited to write a program grant in experimental atherosclerosis. Which they did, and “Frank Yeager came out and looked it all over and said he was impressed with the content and asked a very interesting question of Katz in our presence. ‘Who worked on this?’ And the great man said Jerry, and Ruth and Sy. And Frank Yeager said quietly ‘Probably it would strengthen the proposal if you would put them down as co-principal investigators.” [ed. That’s how Jerry Stamler became a co-PI for the first time on an NIH grant. All of this was under Jim Watts’ initiative for program grants.]

Bethesda direction and control.

[ed. How did the funding agencies shape the direction and the content of research in the field of CVD prevention and was that all to the good. … in hindsight might that had been done better? Stamler says that federal approach has been good long term and cites his People’s Gas Study and Framingham, despite how tough it was to get any proposal in prevention in epidemiology through the American Heart Research Committee.]