“It Isn’t Always Fun.” – Geoffrey Rose
By the Other Half
Weybridge, Surrey, England
April 19, 1991
At the Oatlands Park Hotel, Weybridge, an invitational Conference on Cardiovascular Disease Epidemiology was held in recognition of Geoffrey Rose at the time of his retirement from the London School of Hygiene and Tropical Medicine. Many gave papers and a few of us engaged in personal reminiscences about our friendship with Geoffrey. It was a warm, distinguished, and entirely suitable affair. I recall particularly Geoff saying, as he leaned over the little jazz band I had put together with Richard Remington for the occasion, “I certainly hope there will be jazz bands in Heaven.” To our great chagrin, he was soon to find out if that were so. Geoffrey died prematurely, with rapidly spreading cancer, three years after the conference in his honor. Here are my personal remarks from that occasion. Reference to the book, “Rose and Blackburn,” sets the stage.
“Rose and Blackburn,” the book, began in earnest in late fall, 1964, during the dull gray period when Geneva is covered by unrelenting fog. Rose and Blackburn, the colleagues, were clear about their assignment from Zdenek Fejfar: to prepare in 10 days the first draft of a World Health Organization (WHO) monograph: Cardiovascular Disease Survey Methods. Shut in a cell furnished with two desks, two chairs, and a view eastward on the perpetual mists, we worked with a staff of one bright English secretary. This remains even today the favored WHO method for producing expert reports. First, prepare the groundwork well, exchange manuscripts and correspondence, and assemble the experts in Geneva. Then, incarcerate them until they come up with a draft.
We worked well as a team; Geoffrey in the didactics, principles, and computations, I in the field methods, definitions, and criteria. We overlapped comfortably in places. Geoffrey took over methods in the sections on chest pain, smoking, and respiratory questionnaires, and I took over on principles of organization, operations, and recruitment. We edited each other’s drafts and soon mastered each other’s difficult handwriting. Rarely did I mark his drafts. Geoffrey whittled away mightily, though tactfully, on mine, until eventually I came to acquire some of his parsimony of language. Later, a senior WHO reviewer of the monograph, Alex Burgess, remarked that he had not found, save in a few classic sonnets, “so much information concentrated in such limited space.”
A major part of the effort of WHO Monograph Series #56, finally published in 1968, was “The Minnesota Code,” a system of criteria and procedures for classifying electrocardiograms in population studies and trials. This was primarily my contribution but Geoffrey and I had consulted often during preparation and early application of the code and he was among the first to use it to compare coronary heart disease prevalence among populations. It has never been clear who dubbed it, early on, The Minnesota Code, a label that correctly represents its genesis in Minnesota-based activities. Another of Geoffrey’s contributions to the code was the use of lay coders, which we developed independently on each side of the Atlantic. In Geoffrey’s case, this came as a natural and logical pursuit. On our side, it happened more by serendipity, nurtured by the desperate necessity of coding thousands of records annually. I shall not divert here to the story, known to some of you, in which my eight- and nine year-old daughters demonstrated to my satisfaction one summer that physicians need never more occupy themselves with coding electrocardiograms for population studies. A child can do it.
I would like to share two brief anecdotes, however, about clerical ECG coding, that neither Geoffrey nor I had anticipated. One day, in the early years of the Minnesota ECG Coding Center, I received a telephone call from a Twin Cities hospital. The record room supervisor was puzzled about a young woman soliciting a hospital job as “electrocardiographic coder” who had given my name as reference. The young lady had, in fact, been one of our earlier student coders and was quite good at it. When she, on her own initiative, made overtures to the hospital, they had no idea what she was talking about. The supervisor was afraid that the young woman might not be mentally stable and wanted to warn me that she was making the rounds of local hospitals, offering to read electrocardiograms for a fee and claiming that she learned her skills in our laboratory.
The other story is about a student clerk, fresh out of our 10-day training course. On a holiday return to her small town in northern Minnesota, she accompanied her parents to visit her grandmother in hospital. As they entered the grandmother’s room, a cardiogram was being recorded, actually rolling out of the machine. She glanced at it and reacted spontaneously: “Oh my, grandma! You have a complete left bundle branch block, a Minnesota Code 7.1!” Apparently it took much persuasion and some sedation to convince the dear old lady that she didn’t have heart block brought on by a heart attack, and that her death was not imminent.
Geoffrey Rose, in sum, had multiple roles in the development of standardized survey methods. The “Rose Chest Pain Questionnaire” modified the old Fletcher “Cough and Spit” Questionnaire. He studied the reliability of the Minnesota Code, initiated lay coding and wider use of the code, and he co-authored “Rose and Blackburn,” the WHO monograph on CVD survey methods. All were central contributions to CVD epidemiological methods, leading, we trust, to more reliable classification of attributes and of events for studies in our field.
Life with Geoffrey before, during, and after “Rose and Blackburn,” has been stimulating, and, on occasion, intimidating, at least for one who arrives at decisions and views in somewhat more roundabout ways than does he. Geoff always seems to ask the especially penetrating question, the one that goes to the crux that punctures balloons. For example, when I proposed long-term cohort monitoring in addition to cross-sectional surveys to detect community risk factor changes over time, he asked, “What will your cohort really represent of the community or of the original cohort after 10 years time?” Geoffrey is quick, indeed, to find the core, weak or strong, of the matter.
Geoffrey’s economy of expression derives, of course, from his clarity of thought. His humility about these superior mental processes was manifest in the gentleness of his edits of my efforts on the WHO manual, but it was never more evident than in his response, in late 1990, to comments I made to him after he gave the first Ancel Keys Lecture at the American Heart Association annual meeting. We were seated on tombstones in an old Confederate Army cemetery just outside the Dallas conference hall, discussing his lecture and mulling over our individual futures.
I waxed effusive: “Geoffrey, in your entire Keys lecture there was neither a single wrong word, a single negative word, nor a single excess word,” to which he immediately replied, “Thank you, Henry. Unfortunately, there also was not a single new word!”
Geoffrey may have felt that he had not found “new” words in his marvelous lecture. But his syntheses generally tend to make everything he reviews, in fact, “new.” His formulations provide a pure, sharp, and above all, fresh impact.
For another example, many people, including me, attempted for years to characterize the difference between the forces of risk acting on whole populations and those acting on individuals, and we had devised various and vague terms for the concept. I once published an editorial in the New England Journal of Medicine that contrasted the academic view of coronary heart disease (of the mechanisms, in the individual) with the pragmatic view (born of society, in the population). This crucial contrasting concept never fell together until focused by Geoffrey’s thought and language in his now-famous Lancet paper, “Sick Populations and Sick Individuals.”
In our meeting to honor Geoffrey here this week, a major goal has been to understand not only the mechanisms of coronary disease (CHD) in the individual but also those influences that operate over whole populations and to appreciate the major implications for prevention of the different force of risk in these different settings. Geoffrey often said that others were earlier more population-minded and intervention-minded than he about the mass causes and preventability of CHD. It seems strange today but he once said to me: “It is not an intellectual imperative that the epidemiologist act on his findings of probable cause.” But he evolved in his concept of the public health, and to him surely goes the credit for crystallizing, formalizing, and effectively propagating the epidemiological concepts so critical to good practice and public policy.
Rose’s Prevention Paradox, which states that large numbers of people must participate in a preventive strategy for a direct benefit to relatively few, has provoked other useful ideas. A few libertarians have obfuscated this issue, claiming that mass preventive prescriptions in “sick populations” are an infringement on individual rights. I believe this misstates the case and distorts the Rose Paradox. First, it misses crucial points about the population or mass causes of common diseases, as well as about the population strategy required for their primary prevention. For example, about half of adults in western societies develop hypertension at some period during their average 75-year life spans. Half of these, in turn, die from coronary disease and stroke. It is quite likely that, with effective prevention of hypertension in the first place, they would die much later and healthier. Whatever the case, their individual lifetime cumulative risk of a cardiovascular event is not remote. Thus, it is not just “the few” who benefit from mass prevention strategies.
The Rose Prevention Paradox has also been misused to disparage the population strategy of primary prevention in favor of identifying only adults at high risk and focusing all efforts on them, thus not “penalizing” the masses. This view, in strong favor among many academics and clinicians, presupposes that dealing with the high-risk adult segment of the population would not only take better care of the problem, it would do so more efficiently and cost-effectively. In fact, there is much evidence that such an approach is neither a complete nor an efficient one. First, there is the relative imprecision of identifying high-risk individuals; then there is the late, unexpected, and often fatal first manifestation of the disease. Finally, there is the predominantly socio-cultural determining of average risk factor levels in the population, so that the not-yet-at high-risk, young people, for example, are actually missed entirely when a prevention strategy is confined to high-risk, middle-aged adults. Under these conditions, the epidemic simply rolls merrily along with each successive vulnerable generation. And the high-risk medical strategy of prevention quite avoids the immense challenge of preventing high risk in the first place, so-called primordial prevention, in cultures not yet at high cardiovascular risk.
Another contention of those who, I believe, distort Rose’s Prevention Paradox, is that social decisions playing individual rights against social responsibility, or promoting health and thus creating a demand for preventive services, amount, in effect, to an Orwellian Big Brother state. To the contrary, I suspect that an educational, motivational, and eventually legislative approach to social change is the only truly democratic way for an open and informed society to arrive at policy. I find it a distortion that prevention policy is considered by libertarians as a surreptitious attempt to deprive people of a better life, or of rights earned by industriousness, or that preventive efforts penalize the innocent masses for the sake of a few sinners.
Those closely involved with the population strategy of prevention and with health promotion find that freedom from the “bondage” of personal addictions, freedom from enslavement to commercial manipulations, overt and covert, independence from the economic determinants of unhealthy food products and toxic environments, and liberation from the confines of unhealthy cultural traditions, all represent no deprivation of basic freedoms. Rather, they amount to an unshackling from dependencies and from economic and health decisions made for us, largely without any concern for our health and mainly outside our personal control.
Because of the realities of the Paradox, however, in which prevention does involve change being made among many people, Geoffrey Rose quite properly has insisted on the primacy of demonstrated safety for all community-wide health interventions. He again formulates clearly a view that others and I have long argued, always less effectively than he, that a critical guideline to the safety of a population intervention is its compatibility with a lifestyle to which humans are evolutionarily adapted. Historically recent, “man-made” lifestyle initiatives, such as sedentariness, calorie-dense fatty, sweet, and salty foods and perpetual caloric abundance, along with the widespread chronic use of tobacco and of medications, are now recognized as leading to physiologic maladaptations. The criterion of “adding something foreign” to this evolutionary experience (e.g. pills, and fat and sugar substitutes) should, according to Rose, require another magnitude of evidence for its wider safety. Pay attention, FDA.
In this view, with which many of us would agree, it would be questionable whether any long-term, regular use of a medication or a food additive/substitute, by large numbers of the public, in the management of such mass phenomena as mildly elevated blood pressure or blood lipid levels or body weight, or for helping to stop smoking, could ever meet a priori safety and ethical criteria for a mass public health strategy.
Again my prognostications apparently fail miserably. The world is now awash in lipid-lowering drugs, the “Statins,” along with several varieties of anti-hypertensives taken chronically. So far, they appear relatively safe. Wait a little. Be careful. They are man-made, not natural solutions!
A Population Strategy
As illustrated so well throughout this happy gathering, Geoffrey Rose has made seminal contributions to the public health, directly and indirectly, both conceptually and with new methods, and not only to CVD epidemiology but also to population prevention strategies in general.
There is a story that during Jack Farquhar’s sabbatical year from Stanford, taken at the London School of Hygiene and Tropical Medicine from 1968 to 1969, Jack “played off” Geoffrey against Donald Reid through conversations, first with Professor Reid, who favored clinical trials on high-risk individuals by modifying single risk factors, and then with Geoffrey, who argued for group approaches to multiple-risk-factor reductions that could be carried out in worksites. The British Factory Study, part of the European MRFIT, was then in the planning phase. Apparently Jack would go from Reid to Rose, recounting the objections heard from each. Exposure to these opposing arguments persuaded Jack that the population approach should influence more people overall and in a more cost-effective manner. This led in time to the pioneer efforts in health promotion that Farquhar and his colleagues made at Stanford and Puska made in Finland, followed by others of us in Minnesota and elsewhere. Jack reported that his London stay was an exquisitely “lazy” sabbatical, with time to think “for the first and perhaps the last time,” while sitting at the feet of the masters, Donald Reid and Geoffrey Rose.
Some of us recall Geoffrey’s ideas at that early time about the necessary limits of feasible worksite interventions: that is, a lecture or two from a physician, some brochures from the company nurse, and a few modifications in the cafeteria. If such a program did not work, according to Geoffrey at the time, that was simply too bad; prevention at the public health level would not be feasible. Geoffrey’s thinking during this period contrasted to our plans in the United States for a more intensive and costly multiple-risk intervention trial. After all was done and said, on both sides, I arrived, rightly or wrongly, at the following aphorism about U.S. And U.K. approaches to research in prevention:
British epidemiological studies and trials are characterized in design and operation by much brain and little brawn. In contrast, North American trials are muscle-bound in brawn and seemingly are given little brain. Undoubtedly, better research would be carried out on both sides of the Atlantic if the British were to employ a bit more brawn and the Americans a bit more brain.
The Rose Persona
I return, in closing, to the Rose persona, and to the adventure of writing “Rose and Blackburn.” Geoffrey’s tolerance and kindness are legendary. I wince when I think of the discomfort I must have caused him during those grim, cold Geneva days preparing the first draft. I was then going through the first stages of a long transition to the non-smoking state, one in which I dawdled with pipes and their paraphernalia. I thought I had found that a few pipesful a day — and all the associated diddling — compensated adequately for cigarettes. But I would have ill-supported what Geoffrey did, respectful of my need: gracefully accepting to sit in a room with a smelly pipe day after gray day. No one who attempted to impose that tribulation on me would fail to experience some show of my discomfort.
In Geoff’s presence, one is aware not only of his special directness and insightfulness, but of his genuine caring for important issues, for people, and for the things that are important to people. This is manifest both in his personal dealings and in his humane gestures. There is, for example, a characteristic deference to others in conversation, or even in walking along a city street, which indicates his humility and goodwill. His broader gestures of humanity are illustrated, of course, in his roles in OXFAM activities and as lay Methodist pastor. But his generosity was never more evident than at a celebratory dinner in Geneva on completing our draft of “Rose and Blackburn.”
That particular evening was held at the home of my then parents-in-law, a distinguished French protestant pastor and his wife, André and Magda Trocmé, who had been central to their French community’s harboring of thousands of Vichy Jews during World War II. In 1964, Trocmé was pastor of Saint Gervais, Calvin’s original church in Geneva. During our relaxed evening together, he outlined for Geoff and me his latest missionary project for North Africa, one that seemed quite different from the usual sort of paternalism and proselytizing of Protestant missions. His plan involved exporting Swiss experts to train Algerians to maintain farm equipment. It appeared that, following DeGaulle’s forced departure of the French colons, the locals were for a period largely unable to repair their tractors and thus were unable to harvest their crops on time.
At the close of the evening in which we heard this inspiring story, Geoffrey made a quiet but stunning gesture. After our many days of intensive work, we had on that final day each received an honorarium from WHO, a single, handsome, Swiss 500-franc note. Geoffrey pulled out his crisp new note and laid it softly on Pastor Trocmé’s table, saying, “Please consider this my contribution to your new mission in North Africa.”
I have not been privileged to hear Geoffrey’s homilies as lay pastor, but I suspect that he preaches good sense, which might even bring back to the fold those who have “fallen away” from the faith of their Wesleyan fathers.
Now, Geoffrey, in closing, I hope that you will permit us a bit of skepticism over all this talk today of your imminent retirement. Such talk goes back at least 15 years. The message all along has been that, “When I retire, I will truly retire,” with the idea that there would be a major change in your direction, activities, and creativity. But now that your distinguished public health career has evolved even beyond your distinguished scientific career, I hope and predict that your further career may continue to evolve, and that friends, colleagues, and society will not be totally denied your collegiality and inspiration in CVD epidemiology or in public polity. We trust that we may have your counsel, Geoffrey, if not your direct collaboration, in future undertakings. I think, for example, of the much-needed documentation for the history of our field.
I close with a final illustrative note from the days of our writing “Rose and Blackburn.” It has to do with the order of authorship of the WHO monograph itself and it has to do also with civility. In Geoffrey’s mind, our effort for WHO was primarily to produce a manual of method and procedure. He had no doubt, therefore, that the order of authors should be Blackburn and Rose, since my then contributions were largely methodological. Similarly, there was never any doubt in my mind, because of his outlining of the epidemiological principles, and his major personal contributions to methods as well, plus the strong stamp of his style and language on the monograph itself, that Rose must be the first-listed author.
We left Geneva still at loggerheads on the matter. By correspondence thereafter we quietly lobbied our WHO editor-publisher-friend, Zdenek Fejfar, each insisting on the priority of the other as senior author. In this unique case of “Alphonse and Gaston,” the superiority of my argument won out. Typically, Geoffrey was dignified in defeat. He reluctantly but graciously accepted to be first author of “Rose and Blackburn.”
In the years after he retired, Geoffrey wrote a thoughtful classic, a book called, “The Strategy of Prevention.” Otherwise, he accepted no obligations related to his lifetime career. We missed him greatly but respected his choice. Then, when his life was cut short by cancer, we admired his good a priori judgment.