First National Conference on CVD 1950
Washington, DC, January 18-20, 1950
This historic conference in mid-20th century was the first major national recognition of the importance of cardiovascular diseases on the North American scene. It was sponsored by the American Heart Association and the National Heart Institute and brought together 200 professional leaders who met and wrote their report in Washington, D.C., based on a series of prior conferences and preparations. It was co-chaired by H.M. Marvin, President of the American Heart Association, and C.J. van Slyke, Director of the National Heart Institute, both heading organizations established or reconfigured in 1948. The main objectives of the meeting were to summarize existing knowledge, to find ways of using existing knowledge more effectively, and to define areas where research is most needed. Preliminary work had been done by a small planning group and each of 11 subject-matter committees.
Three major reports emerged, on technical knowledge and research, on community service and facilities, and on professional education. Technical knowledge and research dealt with all forms of heart and vascular disease and their manifestations and research dealt with all medical research modalities, laboratory, clinical and epidemiological.
Conference chairpersons were H.R. Marvin and C.J. van Slyke, with John Ferree, MD, director. The steering committee chaired by Paul Dudley White contained experts including Lester Breslow, T. Duckett Jones, Louis Katz, and David Rutstein. Public health-epidemiology was represented by Alex Langmuir from CDC, who served under Louis Katz, chairman, and by a committee on case-finding and epidemiology that included Ancel Keys and Gilson Meadors from the Minnesota and Framingham studies, and John Paul, epidemiologist from Yale. Representing public health on the committee on treatment and management services was Herman Hilleboe, the New York State Health Commissioner, and, on community services, Harold Dorn, statistician from the Cancer Institute, and Leona Baumgardner from the U.S. Children’s Bureau.
Staff assistants from the Heart Association included Marjorie Bellows, who played a large role in the scientific councils of the Heart Association in later years. From the Heart Institute was Felix Moore, who was central to NIH, Framingham, and later, University of Michigan efforts in cardiovascular epidemiology.
In his introductory lecture, Chairman Marvin described the evolution of the American Heart Association from a body of physicians interested in scientific aspects of cardiovascular diseases into a national voluntary health agency which at its outset had a director of public health activities (Dr. Ferree). [ed. Parenthetically, there is no longer a director of public health or even a Medical Director of the American Heart Association.]
This seminal meeting, which had been in planning for three years, met the acute needs of the new National Heart Institute for guidance in “spending its money in the way that promises speediest control for conquest of cardiovascular disease.” (Reference to this opening address in the Proceedings) Dr. Marvin defined the overall purpose of the conference “to investigate, define, and develop immediate and long-range programs designed to meet the problems of research, education, and community service posed by diseases of the heart and circulation. Second, to coordinate the efforts of all groups concerned with these problems, with the view to gain the most effective use of their resources for all the members of the community.”
Dr. Marvin went on to restate the purposes of the conference: “I think you are here to consider the presence status of our knowledge in relation to all the varied needs of those who have cardiovascular diseases, to determine as accurately as you can the gaps in that knowledge that we should strive to fill first, and to lay the sure foundations upon which programs in all related fields can be dealt, which will have as their objective the prevention of such diseases whenever possible, and the minimizing of its crippling effects upon body, mind and spirit when prevention is impossible.” Thus, prevention was already prominently in the minds of cardiovascular leaders in 1950.
Dr. van Slyke introduced Dr. Paul White to the conference in effusive terms that indicated the central influence of White in the CVD innovations of the day: “I feel totally inadequate to introduce Dr. White by stating his qualifications and experience, but I do want to tell this group that as executive director of the National Advisory Heart Council, Dr. White has given unstintingly of his time and his efforts. We have kept him up at night working. We have had him travel around the country. We have him flying when the weather is too bad for anything but the most hardy airliner to get through, and he always takes it without any grumbling.”
These are familiar descriptions to those who followed Paul White’s pioneering career in all facets of the rapidly evolving field. And it is particularly interesting to see the close and congenial collaboration between the Heart Institute and Heart Association at this early period and the mutual respect and affection in which the personnel held each other. [ed. This contrasts with the testiness of the Institute in respect to the Heart Association over more recent decades.]
Dr. White then painted a picture showing that research had led to a reduced need for hospital beds for patients with dysentery and typhoid fever, thus: “I hope someday the same will hold true for the three major causes of heart disease: rheumatic fever (probably more rapidly than the others), high blood pressure, and coronary arteriosclerosis” (page 12 of the proceedings).
Dr. Katz addressed research issues in terms of “what is known and can be applied, and what is unknown and needs to be learned,” and in terms of need: “Needs for better diagnosis, for better management and treatment, and for prevention.” His research working group made an impassioned plea for research in basic areas and ended with the following admonition for the 1950s: “The road ahead is a long one, but if we put our shoulder to the wheel and work together intelligently, we will lick the enemy by solving, among other things, three main riddles: What is rheumatic fever? Why does high blood pressure develop? What causes hardening of the arteries?” This was greeted by applause.
These conference proceedings are a compendium of existing knowledge about all cardiovascular diseases at that mid-century point. Irvine Page and a group defined hypertension as levels above 150/90 and provided conditions that were associated with hypertension: renal, endocrine, nervous, and cardiovascular. Their report on hypertension contains but one small paragraph on prognosis and only three sentences on prevention: “There is no sure way to prevent hypertension. Whether regulation of the patient’s mode of life will aid is not known. Search for the known causes of hypertension may bring to light a remediable cause. For example, urinary infections should be carefully controlled.”
The hypertension group concluded: “The committee holds no brief for the unique utility of any special discipline.”
The section on arteriosclerosis was chaired by Cowles Andrus and while not using the term “atherosclerosis,” has this prescient comment: “It seems probable that the lipids in the lesions come from the lipids of the blood although direct proof of this is not available. If this is true, any factor that influences the chemical composition, the level, the stability, or the physical state of the lipids in the blood may be of importance in the pathogenesis of the disease.” “Arteriosclerosis in man develops earlier and more frequently in individuals with high blood cholesterol levels than in those with normal blood cholesterol, but there is not evidence that a level of blood cholesterol higher than normal is essential to the development of arteriosclerosis in man.” And the group opined: “Preoccupations with the investigation of blood lipids in relation to the pathogenesis of arteriosclerosis has led to neglect of other factors.”
In the session on disease of the coronary arteries, after discussion of the frequency and the sex ratio, they discuss the operative factors: “. . .infectious diseases occurring particularly in early life, excessive smoking, the accelerated pace of modern existence, and the dietary regime rich in fats in countries in which the scale of living is relatively high.” Prevention is mentioned only once: “The search for its fundamental causes (that is, coronary arteriosclerosis) must be pursued diligently so that prevention may become a reality.”
Alex Langmuir gives a lecture on epidemiology. He presages Geoffrey Rose’s “Sick Individuals, Sick Populations” analogy when he defines the differences in epidemiology and clinical medicine: “All the clinician is primarily concerned with is sick persons, the epidemiologist is concerned with communities including both the sick and the well. … the epidemiologist seeks an understanding of modes of spread or of social and environmental factors in causation of disease in order to apply preventive. . . procedures in the community.” Thus are clinical medicine and epidemiology interdependent.
The status of common knowledge and the hopes about the epidemiology of degenerative cardiovascular diseases are reflected by Langmuir: “Considering the primitive state of knowledge of causative factors in this field, epidemiology can take its place alongside all the other disciplines as one with greater future potentialities than past accomplishments.” “The most urgent research needs are consistent criteria and simple but reliable diagnostic tools for counting cases and differentiating the significant categories, syndromes, or specific entities. An even more urgent research needed is a set of better hypotheses as to causation of cardiovascular diseases which can form a basis for further studies. . . The present dearth of hypotheses therefore, is not a valid reason for postponing the establishment of field studies in cardiovascular diseases.”
He goes on to remark that policy on cardiovascular disease epidemiology should support studies from all three sources of epidemiological information: vital statistics, hospital and physician records, and morbidity surveys in defined populations. And he recommended priority to those evincing greatest professional collaboration.
The summary report on nutrition by Conrad Elvehjen, PhD, is a typical conservative, professional nutritional focus on vitamins and proteins and provides no discussion of diet fat and only one relevant statement about lipids: “The relation of cholesterol to arteriosclerosis can only be studied properly under controlled nutritional and biochemical conditions.”
The community services group made a few recommendations on public education for the control of cardiovascular diseases, urging health examinations starting in the 30s, “moderation in diet, weight control, proper exercise, and avoidance of stress and fatigue.” “A fatalistic attitude is unjustified because many individuals with these diseases live long and useful lives.”
There were general recommendations for study of the epidemiology of cardiovascular diseases to include both “scientific and social” disciplines, to state goals and hypotheses clearly at the onset, to study morbidity as well as mortality in cross-sectional surveys and in longitudinal studies to provide a basis for hypotheses of cause and prevention. Clear definition of a case is required and there is discussion about compulsory reporting of cardiovascular diseases with feeling that it was not indicated but that case registries were recommended.
The sub-session on community services shows perhaps an even broader concept than exists today of what the Heart Association and Institute are all about. For example, the chairman of this session, Leonard Mayo, described the purposes of his working group as providing guidance to communities “1) That they may better understand the nature and extent of cardiovascular diseases; 2) that communities may be better able to apply and disseminate present trends . . in knowledge . . to the treatment and prevention of cardiovascular diseases, and in order that they may be stimulated to ask intelligent questions with respect to the gaps that still exist in our present knowledge; 3) that they may be helped to establish and maintain practical facilities and services for prevention, treatment and control and to sustain a continuing and intelligent program of public education based on a higher motive than fear; and 4) that communities may be aided to effectively mobilize, coordinate and continually evaluate such services as an integral part of a broad, inclusive program of public health.”
[ed. There has been no more eloquent presentation of the roles of the Heart Association in the community. It was also interesting to see the term “a roadmap for communities.” in this report of the Community Services Committee, and the comfort of cardiovascular leaders of the time in addressing a public health issue at the community level. This contrasts with comparable meetings of today that are focused on high-tech medical or public health strategies, rarely their combination.]
Mayo went on to say: “It is important …. to recall that communities are as different as people, but like people, they have certain basic things in common. In other words, as a person behaves and as a group behaves, so in its own and peculiar and special way a community behaves. A community has a social history, a pathology, which means that it is subject to constant change. It is influenced by positive as well as negative forces.” He continued to say that, rather than a blueprint for what to do, the conference should seek “rather a roadmap for communities which will give a sense of common direction and the experience of other people in trying to meet a given goal. . . what every community should know about cardiovascular disease.”
The conference was considered a success due to the comprehensive advance material, selection of the participants based on ability rather than geography, the staff services provided to the well-managed committee meetings, and the combination of professional fields and skills within each committee, involving physicians, nurses, teachers, and social workers.
Abel Wolman, an engineer, summarized by drawing a parallel to a conference held at the turn of the 20th Century to consider the major killer of that time, tuberculosis. In it he depicted a struggle still found today “between the perfectionists and the opportunists, a struggle as to whether you are able to begin any kind of campaign until the last iota of scientific information is available. On the opposite side was the opportunist, who would begin his campaign without an iota of information. In between, there was this wise and intelligent group which decided, equally wisely, that you start a campaign when there are an accumulated set of facts which are sufficient for the purposes of saving lives . . . .”
He quoted Harry Mustard who said, “A health problem becomes a public health responsibility if or when it is of such a character as to be amenable to solution through systemized social action.”
American Heart Association. Proceedings First National Conference on Cardiovascular Diseases. New York: American Heart Association, 1950.
[ed. There probably has not been a more thoughtful and well-organized multi-disciplinary conference dealing with the needs for research, training and education in cardiovascular diseases than this 1950 conference. The only subsequent report that remotely resembles its comprehensiveness and global view is the Joint Commission Report in 1970. (Report of the Joint Commission 1970) One wonders if such a unifying approach might again be useful to attempt today. (Henry Blackburn)]