Paul D. White and James Watt: The Early Vision of CVD Leaders, 1956

The Vision Thing: 1956

At the first major symposium presenting data from prospective CVD epidemiological studies among U.S. cohorts,(1) the prescience and vision of two pioneers is manifest in the conference introduction by Paul Dudley White, then just-resigned Executive Officer of the National Heart Institute’s Advisory Heart Council, and in the conference summary, by James Watt, then the effective Director of that institute.

We see their early vision about the uses of CVD epidemiology and their understanding of its then urgent needs for sound methodology and proper design, their priority for the study of modifiable risk factors, and their encouragement of interdisciplinary thinking and research. From their words at this milestone conference, we see their early grasp of the facts that segments of the population are at high and others at quite low coronary risk and of the power of cross-cultural observations and research collaborations in science as well as in international relations. We are made aware at that early date of the very real promise of secondary, primary, and primordial prevention.

In these simple statements, we can see medical vision and leadership at its best.

The Cardiologist Enlists the Epidemiologist: Paul Dudley White

As one grows older in medicine, one naturally tries to unite the preventive aspects of health and disease to the care and advice one gives to one’s private patients and their families. I spend a certain amount of time nowadays in advising fathers and mothers who are ill with heart disease about the future of the health of their children and of their childrens’ children.

At first is was natural that our chief interest would be in the improvement of the diagnosis and treatment of the disease [coronary disease], but about 20 years ago attention began to be focused on a study of its causes. Today we cardiologists realize the importance of enlisting the help of many experts in other fields in our attempts to solve the problem.

Laboratory experiments on animals and clinical and laboratory studies on man have been done fruitfully and should be continued, but a much neglected field, the surface of which has barely been scratched during the last five or 10 years, is that of the relationship of the ways of life to heart disease, which we have come to call epidemiological cardiovascular research (1).

It has been only in the last few years that some of us have ourselves gone actively into the field, meanwhile hoping to enlist those who previously had been especially trained in epidemiological methods, which, of course, in the past have been used largely in the fields of infectious disease and malnutrition. The day of united effort is now dawning and we cardiologists must take advantage of the experience and the skills of the professional epidemiologist, while he in turn must learn about cardiovascular disease and get from us our firsthand experience the this malady. We must always take advantage of lessons learned in the field (2).

The cooperation of the family doctors is now most encouraging. A recent visit to Grand Forks, ND, has demonstrated this to me. At a breakfast conference on a Sunday morning, more than 100 of the 135 total medical community assembled to discuss their part in the survey of coronary heart disease in the six northeast counties of that state, with fringes in Canada and western Minnesota in the Red River Valley. From a study such as this can come much fruitful information, especially when a comparison can be added between such people living in their community of rich farm land with others of the same race living under far different circumstances. This type of investigation is new, complicated, difficult, and expensive, but it must be done and with the greatest care.

Finally, here is an opportunity for the establishment of international medical cooperation.

Summary: James Watt

I would like to present a reverse twist to Dr. White’s presentation and say that the epidemiologist needs to turn to the cardiologist. I say this because the major problems in the study of the epidemiology of coronary disease today are numerator problems, as was amply demonstrated by the other four papers on this panel. It is now impossible to get a definition of coronary artery disease which permits a clear separation between those with the disease and those without.

It may be that this methodology, which in its present state does not clearly separate all the diseased from the well, is reproducible enough that it can be used as a tool to produce an index of coronary disease in populations. Such an index could be used to study populations which differ by those characteristics thought to influence the occurrence of this disease.

Analysis of multiple characteristics along the lines that were reported from the Framingham Study, will, I think, eventually make it possible to accurately characterize a population in which susceptibility to coronary disease is very high. By the same token, highly resistant [low risk] populations may be delineated.

I think we will see many other health departments embarking upon epidemiological studies of coronary disease, or for that matter all the chronc diseases, in the near future (63).

^[1] Measuring the Risk of Coronary Heart Disease in Adult Population Groups. American Journal of Public Health 47: 1-63, 1957.

Presented at a Joint session of several sections of the American Public Health Association in Atlantic City on November 15, 1956.