“If It Isn’t Fun.” – The Makarska Conference and 10-Day International Seminar on Cardiovascular Disease Epidemiology, Dalmatia, Yugoslavia, September, 1968
It may be hard to imagine now the intensity and vigor of the field of CVD epidemiology and prevention in fall of 1968. The population evidence was in on the major risk factors of diet, serum cholesterol, blood pressure, and tobacco. They were strong, consistent, independent, and universal predictors; the mechanisms and pathways were plausible; and the findings were congruent with those from the clinic and laboratory. Thus, causal inference was great. But the two primary initiatives taken toward experimental tests of risk-factor hypotheses, the National Diet-Heart Trial and “Jumbo,” the first proposal for a multiple-risk-factor trial, were dying on the twin barricades of academic resistance and national cost.
Then a few clear heads began to focus, laying out the irrefutable evidence and proposing a multiple-strategy, national research program that could carry the day for prevention. At Makarska, on the romantic Dalmatian coast, it all came together in a plan.
It is difficult from the present perspective at the millennium to separate the designers from the architects from the builders from the workers involved in the Great Leap Forward of CVD preventive studies that took place in the next decades. But they all came or sent their delegates to Makarska in September of 1968. In fact, they assembled there because of Ancel Keys and the “Minnesota show,” the 10-year follow-up field survey of the Seven Countries Study. And the old-boy club, the Keys-White Research Committee, by then the Council on Epidemiology and Prevention of the International Society and Foundation of Cardiology, had new movers on board: Jeremiah Stamler, Geoffrey Rose, Richard Remington, Fred Epstein, and Henry Taylor, among others. They were working together with the wider community and with the key agencies, the American Heart Association and the National Heart and Lung (not yet Blood) Institute, and the World Health Organization.
World leaders in CVD epidemiology represented at the Makarska Conference and its First International Ten-day Seminar in CVD Epidemiology included the following:
Left to right: Henry Taylor, Thomas Chalmers, Austin Heady, Jeremiah Stamler, Samuel Fox, Richard Remington, Gösta Tibblin, Igor Glasunov, Geoffrey Rose, Frederick Epstein, Martti Karvonen, Ancel Keys, Jerome Green, and not visible taking the photograph, Henry Blackburn.
My generation were there as national delegates, as survey team members, and as fellows or faculty for the first Ten-day Seminar in CVD Epidemiology. That seminar was an important, if then poorly prepared add-on to the intellectual feast that was Makarska in fall, 1968. Of course, we muddled through for the seminar, the less-effective pedagogues buoyed by the masters: Rose, Remington, and Stamler. These three big guns, joined later by Rose Stamler, carried the seminar for the next decades as it became a major influence in the international development of CVD epidemiology.
After summarizing the evidence and possibilities for prevention, the Makarska conferees proposed a series of initiatives in a framework for action. Moreover, those needed to take action were on board, from the AHA, from NIH, from WHO, and from the Joint Commission on Heart Disease Resources, all the agencies that were to develop the seminal policies and programs of the ensuing years: the 1970-71 NHLI Task Force on Atherosclerosis, the Report of the Joint Commission on Heart Disease Resources, and WHO Expert Reports on preventive trials and community strategies — all essential sources of national policy and program.
Much of the thrust in CVD epidemiology and prevention up until today may be considered an extension of those plans and initiatives: the cohort studies and the primary and secondary prevention trials of the 1970s, the community surveillance and intervention projects of the 1970s and 1980s, and national public policy with prevention programs. The Great Leap Forward of prevention was under way. Simultaneously came a dramatic decline in cardiovascular risk levels and death rates in industrial countries. This continues there, though now abated and incomplete, into the new millennium, while the opposite epidemiological transition gets underway among societies in economic transition.