Gunnar Biörk: A Leader Turned Skeptic
What turned Gunnar Biörck, leading cardiologist of Sweden, away from CVD epidemiology and preventive cardiology, in which he showed such keen interest in the late 1950s? A little red book published of his 1974 Lilly Lectures at Oxford and at the Royal Society in London provides clues.
Having done excellent clinical and statistical studies, with Malmö, Sweden, and its hospital as a community model for coronary heart disease, and after recruiting Gunnar Blomqvist and other Young Turks into the field, Biörck quite abandoned the subject of prevention. He did not subsequently use his several pulpits to criticize it, as did his Swedish colleague Lars Werkö, after a similar brief affair with epidemiology, but he moved far away, and, it was reported, grumbled from time to time about “risk factors” and those who “decreed lifestyle changes” on the population.
His departure might well be attributed to the assumption of heavy hospital duties at the Seraphimer in Stockholm, then of parliamentary responsibilities and also as physician to the royal family. But it appears that epidemiology hadn’t the immediate promise of returns, as he recounts on page 19 of his little red book:
“I had the privilege to study human heart muscle myoglobin and cytochromes under the guidance of two future Nobel Laureates, Hugo Theorell and Christian de Duve, in the hope that the respiratory chain might be crucial to the problems of ischemia. This, unfortunately, was not to be the case. [Moreover] in the early 1950s, I was given a chance to work with Paul White and Ancel Keys in their international attack on the epidemiology of coronary heart disease. The set-up in Malmö proved ideal for a comprehensive, hospital-based investigation of ischemic heart disease in a community. [But] neither of these approaches appeared to be particularly useful under the circumstances prevailing in the Seraphimer Hospital at the end of the 1950s. With the acute mortality in patients with myocardial infarction remaining at the 30 percent level since before World War II, the necessity to ‘do something’ about it was imperative, both as regards the immediate treatment and in the search for pathogenic mechanisms that might render prevention feasible.”
Later, he explained: “We therefore set out to study patients with ‘heart attacks,’ following the clues in different directions. . . . We have done little in the way of conventional epidemiology, neither have we done very much in the lipid business or with regard to coronary surgery. Our policy has been to try to explore areas and problems that were not quite ‘in’ at that time, such as carbohydrate metabolism in relation to ischemic heart disease, and–in particular–the genetic aspects with regard to both biological and psycho-social factors. . . Over and above, however, we have tried to follow the advice of that great Regius Professor of Medicine at this University [not named, but presumably George Pickering] who stated: ‘If you have the good fortune to command a large clinic, remember that one of your chief duties is the tabulation and analysis of the carefully recorded experience’” (Biörck 1975, 19-21).
Later in this lecture (page 42), we see signs of more skepticism: “Through a combination of prospective and retrospective data it has been possible to identify a number of factors that characterize the pre-infarct person and tell us who the pre-infarct patient is. They have usually been called ‘risk factors.’ Personally, I prefer to call them ‘indices,’ biological or psychological, because I do not think one should jump too fast in making inferences here.”
And again on page 45, we see a hint of libertarian objection to public advice on health, and of his going his own way: . . . “despite the ambiguity of the WHO–which in one document recommends the governments to ‘change the modern way of living as such,’ and in another feels that ‘no relation has been found between personality traits and the risk factor score, whence psychological factors should not be given prominence in prevention trials’– we have attempted to study precisely such factors.”
Despite this investigative quirk, Biörck held advanced concepts of the social issues surrounding common diseases, shown in this comment on page 69: “In such endeavors . . . it has become necessary . . . to attempt a reconciliation of our concepts of disease, and illness, in the individual patient, on the one hand, and those of the impact of our environment on the etiology and pathogenesis of human disease on the other . . . With regard both to ischaemic heart disease and to hypertension, the search for ‘causes’–which is the preoccupation haunting physicians and patients alike–has carried many of us away from the circumscript province of the body and into the vast morass of contemporary society. But in carrying our case outside our own medical territory, where our competence is rarely challenged, into an area where most decisions are ‘political,’ in the wider sense of the word, we must examine both our arguments and our procedure very carefully. If we really think that specific factors in our society are ‘pathogenic’ and cause disease, we must say so” (pages 68-70).
But the latter, Biörck was by nature quite disinclined to do.
So there we are. He found that epidemiology offered neither treatment nor cure in the short term, and little about mechanisms. And as one inclined to take the road less traveled, perhaps even the contrarian way, he moved out and away, and was never again seen around the den of epidemiology.
One might have expected a longer and broader view from such a distinguished medical philosopher and leader, perhaps one reconciling the evidence and views from several disciplines, with needed recommendations for the public based on the best evidence available. That, too, was not to be. Gunnar Biörck was either too skeptical–or too modest. (Henry Blackburn)
Biörck, G. 1975. Contrasting Concepts of Ischaemic Heart Disease. The 1974 Lilly Lectures given at Oxford and London. Stockholm: Almqvist and Wiksell International.