Newton Heart Demonstration Program. Framingham’s 2nd Cousin1949-54
Two Boston-area projects in cardiovascular disease prevention, Framingham and Newton, were set up in tandem by the U.S. Public Health Service in the late 1940s, both of which were affiliated with David Rutstein’s Department of Preventive Medicine at Harvard. Little has been written about the history of the Newton Heart Demonstration Program, which was addressed to issues of screening and disease control and was projected only for three years. It led to no successor, apparently because the CVD screening tools of the day were poor, the community of physicians may have regarded it as a federal intervention into practice, and because it was thought to be of meager benefit to its screenees. According to critics at Framingham, Newton participation had little of the motivating “sacrifice for Science” that became the hallmark of Framingham and other prospective studies of the time.
William Zukel, young PHS officer recruited from a hospital residency to work on the Newton Study, described the project in a letter that may be the only personal account of its activities. He wrote that the study’s first director, Louis Robbins, was assigned by the Massachusetts State Health Department “to locate a suitable community to undertake a study of the prevalent types of heart disease and what might be done to improve prevention and treatment” (Zukel 2001). Newton was chosen, largely, it appears, because of its convenient proximity to Boston and Framingham.
Robbins and a committee of local physicians developed, according to Zukel, a “fairly successful program . . . that included a popular monthly feature series for physicians by prominent Boston cardiologists,” including a “lead-off lecture by Paul Dudley White , which helped drum up local medical support for the undertaking” (ibid.). Zukel summarized the study’s areas of concentration:
“One was in nutrition because doctors were having problems with their congestive failure patients; the possibility of low-sodium diets in hypertension was emerging then. The second area was in hypertension itself . . . [Doctors] weren’t seeing patients with hypertension until fairly late in the stages of the disorder and [they thought] probably it would be good to have a case-finding program in the community–something that could be well organized, particularly in employee populations where you could set up screening programs.”
“Another program was to try to prevent rheumatic fever recurrences in children who [had] had one attack and who were coming down with a new strep infection and didn’t get treatment quick enough.” (ibid.)
The most visible product of the Newton study, at least among the public, was a booklet for physicians’ use in prescribing diets based on three levels of sodium restriction. Staff nutritionists used it to help patients plan meals and make changes in their eating habits. Zukel recalled: “that particular publication got to be so popular that the health department made money selling it outside of the Newton community. Many thousand copies were sold around the country” (ibid.). Modest achievements in rheumatic fever control eventually were claimed, as well.
William Kannel, as a young Public Health officer already involved with the Framingham Study, was asked to appraise the research value of the Newton program. He said that he saw little potential for new investigation when what was being implemented was “an established thing,” namely medical treatment of rheumatic fever and its prevention using penicillin. “I said, ‘Look, this is a government-sponsored program. We cover the cost of everything, we are the motivator, we’re carrying it out; the local people have not really invested anything in this personally, and my prediction is that when we leave, it will fold.’ That’s exactly what happened” (Kannel 2002).
Egon Kattwinkel, chief of medicine at the Newton-Wellesley Hospital, headed up the Newton Study after Robbins, and asked the question, in his report of the program’s three-year experience: “What have we learned . . . about the community approach to the ever-growing problem of heart disease?” (Kattwinkel et al. 1952, 595). His report took care to involve all community interests: the local medical profession, the Commissioner of Health for Massachusetts, the public health department head, and William Zukel, the PHS Medical Officer. These key figures had bent over backward to convince the practicing medical community that the Newton project was not “practicing medicine” and was no forerunner of the grand bugaboo of that era, “Socialized Medicine.”
After this report appeared, the Newton Study figures little in the subsequent history of cardiovascular epidemiology, despite being a local issue of considerable import at the time. It was well described, however, in a series of publications in the New England Journal of Medicine from 1949 to 1951 and in several talks before the Massachusetts Medical Society.
Kattwinkel answers his own question glowingly about what the project achieved, here paraphrased: that medical knowledge about the prevention of rheumatic fever and subacute bacterial endocarditis can be applied in a practical way in a community, that hospital services can be carried over into the community to prevent these complications, and that such a program of education and added facilities complements the medical care rendered by physicians in the home and in the hospital. He also claims that services were improved in nutrition, community nursing, and rehabilitation, all as applied to prophylactic measures for rheumatic fever and heart failure. Approximately 80% of patients known to have rheumatic fever in the community came under active care and treatment of sore throat and recurrences. Cooperative efforts among private physicians, public health agencies, and the general public created “wholesome relations” in solving some of the local problems of heart disease (ibid.,595).
Kattwinkel concluded, “In our experience, physicians gave ample support as soon as they were convinced that the program would be planned and guided by a committee formed from their own ranks” (ibid., 597).
The Newton Study closed shop in the third year. Its residuals in the community are undocumented. Of the two prongs of Joseph Mountin’s original vision of a community model for cardiovascular disease prevention: observation and control, Framingham and Newton, “science” trumped “disease control.” Of the two prongs of Joseph Mountin’s original vision of a community model for cardiovascular disease prevention: observation and control, Framingham and Newton, neither “science” nor “disease control” trumped the other. Framingham continues today as the iconic CVD population laboratory. Disease control is in the strong hands of Mountin’s other creation, Centers for Disease Control and Prevention and its closely affiliated State Health Departments. (HB)
References
Kannel, William in an interview by Henry Blackburn, 2002. History of Cardiovascular Epidemiology Archive. University of Minnesota.
Kattwinkel, E.E. 1951. A community heart program. Report of three year’s experience. New England Journal of Medicine 245: 595-598.
Zukel, W. 2001. Letter to Henry Blackburn. History of Cardiovascular Epidemiology. University of Minnesota.