University of Minnesota

“It Isn’t Always Fun.” – Minnesota Community Studies

In 1977 we really got serious about our Minnesota dream, a two-part dream about population surveillance of trends in heart disease and risk, on the one hand, and community intervention for their prevention, on the other. The dream had begun to take form in the late 1960s with observations of differences in risk among the population samples of the Seven Countries Study. The Makarska Conference in 1968 outlined the first step of preventive trials among those at high risk, a step that was then politically crucial in the skeptical atmosphere of American medical science. The dream crystallized into a plan for Minnesota when, as WHO consultant, I was a delegate at the organizational conference on the North Karelia Project in Kuopio, Finland, in fall of 1971.

Most of us in cardiovascular disease (CVD) epidemiology at the time considered that congruent evidence from analytical studies on individual and population risk was already adequate for initiating public health strategies of prevention. But the politics of the time required randomized clinical trials in high risk people before “establishment opinion” would support such recommendations. As for surveillance of cardiovascular disease trends, we at Minnesota were already clear in our minds about the importance of knowing just where we were as we initiated broad community interventions. It was our idea to first detect, document, and, if possible, explain differences and on-going trends in risk levels and disease rates, then to intervene in a controlled fashion on whole populations at increased risk.

Systematic regional and national surveillance came to the fore in the mid- 1970s, just before and after the bombshell of Weldon Walker’s JAMA article,* which aroused consciousness that we were full in the midst of a major decline nationally in coronary heart disease (CHD) death rates. It took that hard-headed, observant practitioner to point out the mortality trends to all of us fancy-pants epidemiologists and vital statisticians who had, in essence, missed it. It’s not always the guy who discovers the phenomenon who gets the prize. More often it’s the guy who popularizes the issue. In this case, Nemat Borhani had found and published the significant if unsung trend downward in cardiovascular disease deaths, starting among California women, in the early 1960s.

[I never asked Nemat why, untypically, he failed to ballyhoo the primacy of this California finding; he was so delightfully without reserve in all other aspects of his life and career.]

At any rate, in 1978-79 the Minnesota two-part dream had begun. Its conclusion is not yet.

* Walker, W. JAMA

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