“It Isn’t Always Fun.” – Minnesota Heart Health Program
Over the years it became increasingly clear from abundant evidence that the population burden of common maladies, including heart attacks, is importantly due to social and cultural influences. Furthermore, we and others documented that the population rates of common diseases change significantly over relatively short periods of history. The Minnesota Heart Health Program (MHHP), a community demonstration of systematic health promotion, was born of these facts and realizations.
Though a lifetime experience led to this population view of causality, the dramatic demonstration of population differences and of rapid trends in heart attack rates in the Seven Countries Study was the more compelling evidence. A mass strategy to modify population risk of heart attacks had been simmering in my and others’ thinking for a number of years, but a visit to Joensu in Karelia in the fall of 1971, as delegate in a WHO advisory group, was the clincher. In that remarkable region of Finland, the Seven Countries surveys had documented the highest saturated fat diet, the highest average serum cholesterol values, and the highest rates of heart attack found anywhere. Repetition of these findings eventuated in the dawn of community awareness of its unique problem. A truly grass-roots phenomenon then developed that turned the tide of heart attacks in Finland.
We had observed in quinquinnial visits to that region for the Seven Countries Study surveys that the response to our meetings with community leaders, and the news reports at the completion of each survey, became progressively less friendly. After years of acceptance with smiles and toasts of their situation, at the top of heart attack and stroke rates worldwide, the local leaders eventually became troubled. They wondered aloud why this were so, and then insisted that we propose what might be done about it. The press reports became aggrieved and finally aggravated. The community by then was aroused.
These sentiments were egged on by the quiet hand of our Finnish colleague, Martti Karvonen, who had invited the WHO consultant group to lend credence to the effort begun among the local medical and political figures of Eastern Finland. Also attending this first organizational meeting was a young physician, Pekka Puska, who had caught fire with a healthy ambition to affect the cardiovascular disease experience of that afflicted region.
They were off. The North Karelia Project had begun.
I was sorely influenced by that early meeting in Karelia and was determined that at the earliest opportunity we would field a Minnesota model of a community-based heart health program. But MRFIT and other preventive trials among high-risk persons were just getting underway. Several years were required to consolidate new directions for the Lab back home and to get crucial grants and faculty in place. When those activities, that support, and those personnel were finally on board, in the mid-1970s, I was able to attend to our long-anticipated community-wide prevention ideas, the joint Minnesota Heart Survey (MHS) and Minnesota Heart Health Program (MHHP).
Minnesota lay at that time in the lower third among the contiguous 48 states in coronary heart disease death rates, though heart attack was nevertheless the leading cause of death. We were just becoming aware of the downturn in regional and national coronary death rates in the U.S. In fact, it takes four to six years to be secure that any directional wobble in reports of vital statistics represents a real trend. During this period we were encouraged by the Three Towns Study of Stanford led by Jack Farquhar and colleagues. Their small-scale combined high risk and population prevention strategy seemed to be making inroads into community acceptance of and participation in health promotion.
With Minnesota prevention trials delegated to competent hands, I was able to recruit outstanding additional people; we anticipated they would be central to these developments: Richard Gillum, to focus on the community surveillance aspect, and Russell Luepker, to pursue the community prevention strategy. Our proposal in 1978 for a Minnesota Community Prevention Program (MCPP) (clearly a misnomer; we were not trying to prevent communities!), was our personal commitment to a community-based heart health promotion program under a scientific design for evaluation.
During this period I served as consultant to Stanford’s Heart Disease Prevention Program, which was already developing the design for its Five City Program. I was pleased to lend my energy to their projects, all of which helped us in our thinking about a unique Minnesota model. Meanwhile, in my early conversations with Russell Luepker, and particularly upon his arrival in Minnesota, it was clear that he was keenly interested in such a community strategy and had, in fact, incorporated the idea completely into his thinking. This kind of enthusiasm and identification was crucial to the success of our efforts. But his driving ambition to direct the program, and, in fact, as he told me on arrival, to direct the Laboratory itself at the earliest date, introduced a slight complication. Miscommunication developed between us.
To give Luepker greater ownership of the community program we were attempting to launch, I suggested that he write the first draft of the body of a grant application and carried his eventual draft with me on a trip to the Orient in fall 1977. There I edited it, commenting in great detail, and mailed it back to him from Singapore. Such was the poor state of our communications that for the next several months I assumed he had read my edits and wondered why he wasn’t responding. He, in turn, assumed that I was foot-dragging over editing his draft, which he had never received by the post from my Singapore hotel. When we finally discovered the miscommunication we were terribly behind schedule. We both then got into high gear and moved things forward, such that we were able to produce a proposal and have it site-visited, the first time, by the fall of 1978.
Elaine Stone, then a sociologist from an Arizona university, was a site visitor among some 20 others at our first visit; in time she became NHLBI Project Officer for the three health promotion programs, Stanford, Minnesota, and Rhode Island. We suffered then, much as the JUMBO Project had suffered earlier, from a large number of specialized on-site reviewers. NIH policy is to appoint an expert or two for every discipline represented within any proposed research (e.g. youth behavior, adult behavior, nutrition, communications, design and analysis, smoking experts, blood lipid experts, blood pressure experts, etc., etc.) We tried to point out how the dumping of such a mass of people, competent in narrow specialties, into the ambiance of a program with such a broad scope almost inevitably results in an array of priority scores approaching a normal distribution, the average score of which represents neither rejection nor endorsement, but is, in fact,“unfundable.” To no avail.
[Despite no direct evidence to support it, I suspect that a half-dozen people imbued with a broad view of the public health and having a wide experience of epidemiological analysis and interventions would be able to come to a clear and just and expeditious decision about whether such a major project should fly, be tabled for revision, or be rejected.]
At any rate, the second time around, in 1979, we and our application were stronger (we were now called the “Minnesota Heart Health Program”). Jack Farquhar appeared before the site visitors as our consultant and, after he had participated in discussions for a day and as he was leaving the meeting, he was asked the following question by a skeptical reviewer:
“Dr. Farquhar, just how similar are the Minnesota and Stanford studies?”
Jack replied without hesitation:
“They correlate at about 0.7,” and with this cavalier pronouncement he left for the airport.
I was livid. I felt that Jack, our long-term friend and colleague, had demeaned the originality of our six-city control and phased-entry design, our balanced intervention scheme, and the crying need for studies complementary to Stanford’s, as well as the many months of work and years of ideas we had put into our Minnesota proposal. [Now, in 20-years retrospect, I find Farquhar’s 0.7 correlation pretty much on the nose.]
The Stanford Program was born out of what we in Minnesota considered at the time to be high-falutin’ social-learning theory, swaddled in social science jargon. The Minnesota Program, in contrast, came out of direct observation in surveys, in community experience, and in large prevention trials, plus what we considered a healthy pragmatism. We addressed a mass problem of cultural norms that needed to be changed. We proposed to attack population risk both directly and indirectly in a multi-pronged strategy. We planned from the outset that the intervention would be balanced, to employ on the one hand detection of high risk and direct education in screening clinics and professional education, and, on the other, organization of the community’s schools, industries, and other institutions to promote health. All were to be made aware and motivated through mass communications. Our Minnesota bias was toward a balanced thrust in involvement of the community. We found Stanford’s project weighted heavily with mass communications and social theory, and Pawtucket’s we considered a restricted emphasis on professional education and community organizations. Or so we glibly thought at the time.
NHLBI had its own plans for these three free-standing community research-demonstration programs, at Stanford, Minnesota, and Pawtucket, heavily vested as it was in these studies that would last a decade and cost a great deal of money. Each program, after all, sought the same goals of reducing coronary risk through multiple community and medical strategies. Moreover, NIH, recognizing they were dealing with three strongish characters as PI’s, Farquhar, Blackburn, and Carleton, wanted to see the independent studies at least coordinated centrally if they could not be directly controlled (ours were RO1, investigator-initiated grants, not contracts). So the institute set up and sponsored a Coordinating Committee under Elaine Stone. In time, we each saw the advantage to our individual programs to simulate the stronger characteristics of each others’ programs, and, indeed, we became more and more alike (eventually probably even greater than Farquhar’s initial estimate of r = 0.7).
[I assume that we may be permitted a Minnesota bias here, even at this distance of two decades, that ours was the stronger design of the three U.S. community studies, having three treatment and three comparison communities, with an internal control derived from staged entry into those communities, plus ongoing screening, direct education, community organization, and mass media. So it still seems to us. Strength of design is relative, however, in such a quasi-experiment, among so few, non-randomized communities in the same geographic region and exposed to so many intervention vagaries and so much sampling variation.]
During this tumultuous period of getting MHHP underway, I was flailing about to find competent administrative help for the division. Our budget had increased 10-fold in a short time. The long-term LPH administrator, Nedra Foster, had retired. The young administrator from the ECG Coding Center had a calm and chatty managerial style well suited to the old Laboratory of Physiological Hygiene with small staff and few grants. But with such great expansion and complexity we needed professional skills in accounting and personnel administration, plus lots of hustle and efficiency. At this juncture, we were willed an experienced administrator from a distant study, a man with deep family and personal problems not disclosed to us on hire. At the end of his first year administering MHHP, we found ourselves $225,000 in deficit; our supposedly brilliant and senior administrator was, it turned out, going home at three o’clock in the afternoon, drinking himself blind, coming in blow-dried in the morning, pretending he was an effective citizen. Several efforts at his replacement were disastrous.
We eventually found gold in our own mine, the young director of our computing center, who had little experience but much savvy and who was completing his MBA. Within a few months of his charge we were well on the way to making up the deficit and were fully engaged with the University administration, which then approved construction costs of adequate new quarters for MHHP in Stadium Gate 20.
Skeptics of MHHP in High Places
Returning in this story to spring, 1978, Russ Luepker and I presented our initial plan for a community project to Lyle French, the Vice-President of Health Sciences at Minnesota and his administrative assistant, Dave Berg. We proposed our project as candidate for a Minnesota “legislative special,” one-time funding to develop and pre-test a proposal for NIH. Without such special funding we felt that we would be stealing time and effort from other grants to prepare such a major new application. These distinguished officials were formally courteous but quietly and firmly negative. In the end, we were not even allowed to compete against other campus ideas being submitted for legislative specials.
A year later, after we had received the first five-year, multimillion-dollar award for MHHP from NIH, VP French came over to visit us in the stadium, smiling affably and offering to “eat crow.” Thereafter, the University at all levels collaborated smartly and generously [much as a bank is happy to grant a loan after you no longer need one ]. In particular, Peter McGrath, then President of the University, and our Dean of Public Health, Lee Stauffer, set things in motion by agreeing to amortize the cost of our needed new construction from indirect costs awarded the grant. We then built Stadium Gate 20, 10,000 square feet more space under Memorial Stadium, which served us and MHHP well for a decade.
From the outset, we considered our Minnesota center strong in every area of community program except for mass communications, where our visits with the director of the School of Journalism had elicited not the slightest enthusiasm. It is not hard to understand that people fail to get excited about giving their lives to others’ ideas. On the other hand, we found him particularly short-sighted. This was confirmed the following year when the new director, Jerry Kline, saw at once what a marvelous opportunity our project was for health communications research. It would permit numerous masters and doctoral projects in journalism and provide subcontracts for a media production unit with purchases of major equipment for his school. With Kline enthusiastically aboard, we were up and running, strong in population surveys and recruitment, in screening and multiple risk factor intervention, in design and analysis, and, now in mass communications. MHHP looked like a winner. And it was fun.
MHHP moved forward with a solid faculty and staff, specialists in dietary interventions and school programs, in smoking cessation and physical activity, a media facility, and community organizers. In Mankato, the lead-off intervention town, we developed colorful exhibits, a screening and education center, community activities with local celebrities such as Minnesota Viking, “Benchwarmer Bob,” flashy TV and newspaper kick-offs, excellent collaboration with an old friend, Dr. John Eusterman of the Mankato Clinic and an enthusiastic local board of directors.
The Mankato Heart Health Board and its vigorous task forces turned out to be the more successful element of our entire program. For example, have you ever gone into a school lunchroom or any restaurant or cafeteria and suggested with authority different ways for them to buy and prepare and serve food? If so, you may be familiar with the angry blotchy color appearing around the collars of those whose bailiwick you have invaded. On the other hand, if your local board appoints the director of the school lunch program and the administrator responsible for food purchases for the whole school district to its community nutrition task force, before long you reap the results of their learning about the fascinating nutritional and behavioral aspects of healthy eating for kids. Mankato school authorities eventually offered us some 144 documented changes in food purchasing and preparation, with attractive alternative selections for the school lunch menu. I suspect we would have been hard-pressed with a traditional strategy to impose even a half-dozen such innovations.
Becky Mullis, our enthusiastic nutritionist-educator, who joined the staff to work at the community strategy, was determined to field an effective and healthy eating pattern program while staying on the good side of the food and nutrition establishment. She walked that fine line quite successfully. Her original programs became widely copied. Of many, I particularly followed “Lean Meats Make the Grade,” a supermarket program that encouraged purchase of lean beef, ground round, pork, and turkey. Our media group turned out the attractive logo, seen below, red or blue on white, as a sticker for approved cuts. The Minnesota Beef and Pork Board provided the materials used by their demonstrators who taught selection and preparation of the lean meat products at the point of purchase.
*Insert foto Lean Meats Make The Grade
The “Dining a la Heart Menu” was widely disseminated among restaurants of our education communities, in which regular menu items that passed our heart health criteria were identified with a small heart label, a program that, too, went nationwide. We were alarmed but not surprised when the North Dakota Beef Producers’ Association took offense at the program introduced in Fargo. The ranchers rode into town with guns blazing, threatening a boycott of all local restaurants that participated in our program. Becky Mullis and I, worried, called in our communications colleagues. They advised us to sit tight and let the community work out the issue. Indeed, the restaurateurs acted quickly, pointing out to the Meat Board how they had collaborated with them for years and how a boycott of their new restaurant program was inappropriate and unwelcome. Their op-ed reply piece in the local newspaper immediately quashed the boycott; the Beef Producers slunk out of town during the night and were not heard from again.
Similarly, parents reacted to our Mankato school program about smoking and wrote the local paper claiming their child was being brainwashed in school by “health nazis” and being converted into anti-tobacco agents in their own homes. Again, we remained quiet and the letter was soon answered by other parents saying what a wonderful thing it was that their kids were questioning the propaganda of the tobacco industry and becoming more aware of the dangers of smoking.
Again, the newly appointed head of our Eating Pattern Task Force in Mankato, a school board member, set his first priority to regulate by fiat the availability of food vending machines in the schools. We, in the background, suggested quietly that the community be exposed first to our eating pattern campaign for a while, to see whether they might then “spontaneously” call for such regulatory changes from the grass roots rather than from the top down. The latter, in fact, happened.
“Quit and Win” was an on-going PR campaign in which children recruited their smoking parents to a cessation clinic where a drawing took place for the grand prize, a family trip to Disney World in the dead of a Minnesota winter. Picture this scene, which actually occurred in Mankato:
A young family of four climb the steps to the aircraft at the town’s small airport, then turn and face the cameras of the local TV station. Snow flakes drift softly down. The camera focuses first on the eight-year-old daughter who had recruited her smoker father, who, in turn, had quit successfully and then drawn the lucky grand prize. When the reporter asked the father about his success in quitting and his future intentions about smoking, the father looked squarely into the camera and replied with humor and pathos: “If I should ever start smoking again, I would have to change my name and move to a distant town, and might not be able to take my daughter and family with me!”
Pretty good “copy” for our program!
Our three intervention communities, Mankato, Fargo-Moorhead, and Bloomington, were purposely chosen to be different in size and complexity of the community and culture. For expedient reasons we chose entirely different types of available program managers from each community: one folksy and “small-town,” one coolly suburban, and one savvy and autocratic, in fact, the town’s former mayor. The newness and intensity and complexity of our program, with its many elements in the community, was overwhelming to these administrators. They responded effectively, nevertheless, each in his own way, to the challenge of MHHP.
Back at the academic center, complexities developed with our attempts at an administrative matrix in MHHP. It took us, for example, an inordinate time of persuasion to get a larger program concept incorporated, by which parents as well as children would be involved heavily in the Youth Program. Eventually the Youth-Parent Heart Health Program had homework assignments, good parental participation, and integration with the community program. Cheryl Perry’s school-parent program, Hearty Heart, became popular, well accepted, and widely copied.
Along the way, a short but full-scale war erupted between Professor Kline and us, when our intervention director, Maury Mittelmark, insisted that the media unit move physically into the stadium headquarters of the program. He felt they should work in daily contact with our experts rather than maintaining a distant center in their familiar environment, journalism’s Murphy Hall on campus. When neither would yield, and this came finally to head-knocking in my office, I had to side with my intervention director. We moved the whole unhappy media lot over to the stadium. As we had seen with a number of mergers over the years, things worked out quickly when the mergees found that there was good reason for the move and when their daily work was facilitated and rendered more joyful by closer contact with their collaborators.
For MHHP evaluation we considered that we had the best survey center available, under Phyllis Pirie, and the best laboratory person in Ivan Frantz, who had led the Lipid Research Center lab. Imagine our surprise and his chagrin when we found that the laboratory, operating daily within prescribed limits of random error, had a serious systematic drift in values over the longer term. This plagued us throughout the study. Similarly, for blood pressure measurements, despite having the outstanding national expert, Ron Prineas, and his enthusiastic and effective helpers in training, we had serious problems measuring trends of blood pressure in the community, with both random error and systematic bias of observers and survey teams. All these common, inherent survey problems tended to weaken our ability to detect or measure small differences in trends.
Meanwhile, the nation’s health behavior was changing rapidly during the 1980s, including that in our control or comparison towns. The steep trend downward that we measured in average risk factor levels for the control communities resembled in no way the flat line of no change that we had hypothesized for them. Eventually, it proved beyond our ability to accelerate these already accelerating changes in the larger community, or to measure risk factor differences clearly attributable to our intervention above the heavy background of local, regional, and national change in lifestyles, behavior, and risk.
Among us MHHP faculty, there were on-going battles over charismatic approaches versus systematic process, over central versus local management, that is, university versus community control. But for me, the greatest frustration in MHHP was over the inordinate amount of time it required to translate a decision for change, or a new program idea, into community action; at least six months. In the frame of a five-year intervention, this left little margin for innovative approaches. As time went on, the evidence became overwhelming that we might not be able to do enough to accelerate those community changes beyond the brisk on-going background changes we observed. We battled on about the alternatives: doing well what we were now doing and measuring the effect, versus applying resources to potentially more promising but untested things.
When I took a much-needed quarter leave in winter 1982-83, I left a hand-written note to Maury Mittelmark baring a number of my concerns and frustrations about the intervention program and its management. He took my note much to heart and went to Russell Luepker offering his resignation. Russell, naturally, was upset for my making our intervention director feel a failure amidst all the other responsibilities I had dumped on his shoulders as I left the country. Maury, however, turned out to be strong enough to survive my misplaced criticism and stayed on. Our working relationship and personal affection strengthened over the years.
We all badly wanted a winner in MHHP. Claude Lenfant and the Institute (NHLBI) in Bethesda particularly wanted winners of its three expensive community projects. In the end, Stanford more or less declared itself a winner and converted to a health promotion resource center. Minnesota and Pawtucket separately and soberly deliberated and somberly concluded from data of our cross-sectional surveys (the proper community unit of measure) that, despite vigorous efforts and innovative programs, we had 1) inadequate design strength to detect changes, and/or had been 2) unable to enhance measurably or significantly the already favorably changing community picture of cardiovascular risk, 3) or both.
Meanwhile, new knowledge, the health promotion movement, and nationwide media had achieved an unparalleled success in changed health behavior. Risk levels and heart attack rates were plummeting nationally as they were in Minnesota.
The “winners” we could legitimately claim as products of our community-based MHHP research were several: a considerable advancement in community study design, an eventually sound program administration and coordination, effective local community organization, and remarkable “reach” documented for a number of specific health promotion programs fielded on physical activity, smoking cessation, eating patterns, school lunches, and a series of food point-of-purchase and group interventions. By all usual program evaluation criteria these were successful public health innovations. They were, however, not enough.
In addition to strengthening and disseminating community health programs and improving designs for their evaluation, MHHP produced substantial monographs, one by David Murray, Design and Analysis of Group-Randomized Trials (Oxford University Press, 1998), which is perhaps the ultimate word in design for strength and inference in community studies; another on community organization edited by Neil Bracht, Health Promotion at the Community Level (Sage, 1990) is now the standard text in the field; and, finally, an appealing book on community-wide youth programs by Cheryl Perry, Creating Health Behavior Change (Sage, 1999). Numerous effective health promotion programs, direct outgrowths of MHHP, are now tested and promulgated in schools and communities throughout our region and nationally. I expect to see other contributions before the influence of the Minnesota Heart Health Program fades entirely.
Admittedly, in the worlds of science and the public health, no one speaks very much these days about bottom-line results of the Stanford, Minnesota, and Pawtucket Heart Health Promotion programs.