Second National Conference on CVD 1964
The 2nd National Conference on Cardiovascular Diseases was held in Washington, DC, November 22-24, 1964, sponsored by the National Heart Institute, U.S. Public Health Service, the Heart Disease Control Program of the U.S. Public Health Service, and The American Heart Association and chaired by Ralph Knutti, Director of the National Heart Institute, and Carleton Chapman, president of the American Heart Association. Honorary Co-Chairmen were Mrs. Albert D. Lasker, Harold M. Marvin, Luther L. Terry, C.J. van Slyke, James Watt, and Paul Dudley White. Conference Director was E. Cowles Andrus, Executive Secretary – Cyrus Maxwell, and the Conference Manager – Helen Lemp, with a very large central advisory committee. (About the only survivors I can recognize are Bob Brandenburg, Howard Burchell, Michael DeBakey, and Jerry Stamler. Maybe a couple others of these are still alive.)
The Conference opened on the day and the hour of the first anniversary of the assassination of John F. Kennedy and the program began with a moment of silent tribute, followed by a note of support from Lyndon Johnson. In Dr. Andrus’ editorial in the JAMA announcing the Second National Conference he referred, of course, to the First National Conference of 1950, and spoke of how both the government along with voluntary health agencies and private philanthropy had risen steadily in the years since the first conference, including investments of $90 million by the American Heart Association and $640 million by the Public Health Service in heart disease research. This was, of course, before the decline in coronary disease mortality had begun, but there was much to say about the decline in deaths from hemorrhagic stroke and hypertensive disease but that coronary heart disease continued to increase, compelling a critical review of progress.
The objectives of the Conference were 1) to examine the cost of cardiovascular diseases in human financial and social resources; 2) to focus on advances since 1950; 3) to report on the state of knowledge and the application of knowledge at the community level; 4) to project the opportunities and future needs in research, training and applications; and 5) to assist physicians and health personnel and the public in application of current knowledge. Four hundred scientists worked on the summary interpretations for the conference.
Dr. Andrus then presented the leading figures in the development of the panel of co-chairpersons and contributors, all of whom had participated in the first conference. He introduced Paul Dudley White, who responded for the honorary chairpersons and compared the circumstances to those 15 years earlier, reading from the detailed daily calendar that he kept all his working life on note cards. And he paid particular respect to Harold Marvin, guiding the Heart Association through a critical period in the ‘40s and to Casius van Slyke, the first director of the National Heart Institute. The two key figures who led Dr. White to take his role as Executive Director of the Advisory Council of the Heart Institute were, as we have learned elsewhere, were Mary Lasker and T. Duckett Jones, the same two people in the background for the National Heart Act and background for the Gofman Cooperative Lipid Study and many other enterprises of the ‘40s and ‘50s. He called Mary Lasker “the Godmother of American Cardiology.” He talked of how he and Luther Terry had helped take care of John Fogerty’s heart attack and their subsequent collaboration and activities of the Institute, and Fogerty’s central role in Congress in forwarding cardiovascular disease developments as well as the National Library of Medicine, heading the House sub-committee on health and made particular comments about Franklin Yeager, administrator of the National Heart Institute Grants Program (who accompanied him to Yugoslavia in 1958 to our opening of the Seven Countries Study surveys). And finally, he commended his colleagues in the International Society, including Ancel Keys and Albert Baer in the bringing together of physicians and laymen for the cause of heart disease and, in his special view, world peace.
James Huntley, assistant Surgeon General, described how the public health service cardiovascular disease study section in 1949 surveyed cardiovascular research and prepared an estimate that they considered quite exaggerated of $5 million a year for the research program in cardiovascular diseases. At that meeting Van Slyke walked into the room, told them to throw away their out of date survey, that we were going to have a National Heart Institute, a Heart Council, a National Heart Program, with resources on the scale never anticipated. “Where once there was a dearth of effort there began to burgeon new interest and new endeavors along the broad front of research, education and community service. The old feeling of despair about heart diseases was replaced by a new philosophy of hope, action and progress.”
John Sampson from Mt. Sinai Hospital in San Francisco, represented Carlton Chapman who couldn’t attend the ceremony as President of the American Heart Association. Congressman John E. Fogarty of Rhode Island then gave a call to battle against heart disease and started out with the anecdote that he had heard Paul White tell about his daughter getting married in a church in Boston. Just about the time the ring was being placed on her finger and everyone was quiet, someone was overhead to whisper, “My, if you ever had to have a heart attack, wouldn’t this be a wonderful place to have one.” He went on to say he was glad to see Dr. White when he had had his heart attack 11 years before. Congratulating the participants that they had planned the conference not for “public hand-wringing and group worrying but for serious action-oriented blueprinting of a battle plan against today’s foremost disease problem.”
The conference opening dinner was presided over by Howard Sprague who provided one joke after another, none of which is worth quoting, with the possible exception of the quotation of Winston Churchill. “Men occasionally stumble over the truth, but most of them pick themselves up and hurry off as if nothing had happened.”
Then John McMichael, not yet Sir John McMichael, gave the blessings of the British upon our activities and exposed his long-term leanings and prejudices, and I quote: “Great ideas in short are born in men’s minds, never – so far – in the computer.” He also said, “Great discoveries are seldom unexpected but rather the result of previous partial observations which are awaiting full exploitation.”
Page 12 of the Proceedings. He quotes Karl Ludwig “die Methode ist alles” OR, method is everything. “After a really new idea is born there follows a long spell of exploitation and developmental research on its meaning and consequences. This often can lead to new discoveries of great importance and in fact it is only while working in the laboratory that new possibilities reveal themselves to the investigator.”
Sprague ended the evening with his worst joke, that of a woman who had picked up 8 children in her station wagon to take them to school and went through a red light. The officer flagged her down, looked in her car and said “Lady, don’t you know when to stop?” and she said, “Oh officer, they aren’t all mine.”
The session began with Irvine Page summarizing all the research and I’ll simply quote a remark that I want to recall. “Perhaps if we realize that a molecular biologist is by definition a very, very small biologist indeed, we could keep things in balance.” An engineer, Abel Wolman, gave his view of developments and had a broader view than most cardiologists there, saying, “—it is time to officially adopt and implement an explicit strategic commitment to the principles of community action, still so dismally behind other scientific accomplishment.” “I must confess that in these proceedings in 1964 or for that matter, of 1950, little attention has been paid to the ‘how’ of implementation.” He even went so far as to propose a third conference in the immediate future on cardiovascular diseases and social action! Based on three major assumptions: 1. “That predispositions to cardiovascular disease may be detected by available diagnostic procedures; 2) that if detected they may be prevented; 3) that if they do occur, therapy is at hand to arrest or to even cure.” “If these assumptions are sharply in error, then community action may in the long run be more harmful than useful.”
A section on epidemiology on page 228 is chaired by Abraham Lilienfeld and participated in by a lot of old friends: Fred Epstein, Fran Goehring, Ian Higgins, Len Schuman, Reuel Stallones, and Warren Winkelstein, among others. And they described the methods of determining statistical associations in epidemiology in two categories, A and B. A- studies of general population characteristics; 1) vital statistics, mortality and morbidity data obtained routinely; and 2) special population surveys. B- studies of individual characteristics: 1) observational studies; a) cross-sectional, b) retrospective, c) prospective, and part 2, human experimental studies. This suggests a good breakdown for our history.
I quote this because it’s obviously from the soul of Abe Lilienfeld in talking about the epidemiological method. “Once associations have been determined, the two general types of hypotheses that must be considered to explain these associations are 1) a causal hypothesis which states that the factor associated with disease is a cause of the disease; 2) an indirect association hypothesis, which states that the statistical association is indirect and non-causal, that it is a reflection of the existence of a common underlying factor which predisposes the individual to have the disease as well as to have the characteristic. This inferential problem then consists of determining the relative plausibility of these two hypotheses. This is usually accomplished by integrated data obtained from experimentation, both animal and human, studies of biochemical and pathogenic mechanisms, and various types of additional epidemiological studies.”
Then he refers to the statement of Languire, the epidemiologist, at the First National Conference on Cardiovascular Diseases, “In the broader problems of the degenerative diseases, epidemiology has contributed little other than to help in defining the problem and to assist in planning facilities to meet it – epidemiology can take its place alongside all the other disciplines as one with greater future potentialities than past accomplishments.” The statement of an epidemiologist about epidemiology and cardiovascular disease in 1950. Rather insightful, I would say.
Some of this segment goes on to say that we have learned much of the influence of environmental factors, such as diet and cigarette smoking, from epidemiological studies. “Despite such solid achievements, there is a clear need for further epidemiological explorations – much of the cardiovascular field remains to be tilled by the epidemiological plough.” They then propose research needs in cardiovascular disease epidemiology.
In a segment on coronary heart disease, Fred Epstein gives a report. “In recent years, epidemiological studies have made highly significant contributions to the knowledge of coronary heart disease by providing quantitative estimates of the frequency of the condition and delineating with considerable assurance a number of associated risk factors.” He then reviews the state of mortality, emphasizing the importance of this cause of death in younger middle-aged men and the study of morbidity, the fact that women have three to four times lower rates than men, and the statistical associations of these events with serum cholesterol and blood pressure. Ending up with the statement: “A composite picture of multiple risk factors thus emerges, but it is as yet not possible to gain a clear view of their relative importance and interactions.” This is 1964, remember.
I would like to quote Epstein’s comment on biological inference: “The ultimate aim of epidemiological studies is to provide, in unison with clinical science and laboratory investigation, a comprehensive understanding of biological mechanisms and etiological relationships within the continuum extending from health, through early susceptibility and pre-clinical disease to manifest illness. While in the field of coronary heart disease much of the evidence concerning etiological factors is still circumstantial, diet is likely to be important through its influence on the intermediate metabolism of lipids and correlated pathways. Other environmental influences, such as smoking, lack of physical activity, and psycho-social stresses, presumably all interact, as does diet, with genetic factors to produce our arterial and myocardial lesions.” He goes on to state that the stage of knowledge is such that the time appears right for definitive field trials of coronary disease prevention through application of current knowledge.
Epstein outlines specific epidemiologic research needs for coronary heart disease:
- More sharply-defined and mutually agreeable criteria for the diagnosis for the various manifestations of coronary heart disease so as to make data more meaningful and more readily comparable
- Development of more sensitive methods to detect disease and especially pre-clinical disease and disease susceptibility
- Development of more accurate and standardized methods for the measurement of risk factors
A search for new risk factors, not hitherto recognized, and methods for their measurement.” “There is a need to establish causal relationships for the risk factors which appear to be statistically associated with the development of coronary heart disease. This difficult task of attempting to prove causality, may be approached through a closer integration between the field, clinical, and laboratory investigation, and, as already mentioned, through the establishment of active, controlled field trials.” That’s on page 225, Epstein quotes.
Stallones give a long paragraph on the present state of knowledge about stroke and Mort Schweitzer and Fran Goehring give several pages on hypertension, 226-228. They recommend long-term studies on the relationship between hypertension and vascular disease and they say nothing at this stage about clinical trials. Sackett and Winkelstein discuss peripheral atherosclerosis and indicate the problem in diagnosis and methodology. Len Schuman, clearly no expert in this, discusses thromboembolism and presents a text book discussion indicating the total lack of information on the distribution and association of environmental and host factors in thromboembolism. He provides a more knowledgeable summary on page 233-234 of general research needs for mortality and morbidity statistics, epidemiological field studies, recommending 8-10 community surveillance studies, my goodness, the recommendation of a field trial in dietary change and spoke very strongly of needs for epidemiology training, including summer courses in epidemiology and establishing of research centers, epidemiological research centers in cardiovascular disease with multi-discipline strategies.
This document, the last official summary I know of, has attempted to put together the stage of knowledge, the progress, the history, and the needs for future research in a more complete fashion than was done in the First National Conference on Cardiovascular Diseases. Since that time, of course, there has been exponential growth in information, in research, and a great fractionation and super-specialization which makes such attempts at summary a gigantic task. (Henry Blackburn)
Reference
Andrus AC and Maxwell CH (Eds) 1965 The Heart and Circulation. Second National Conference on Cardiovascuar Diseases. Vol I/Research. Federation of American Societies for Experimental Biology.
“The Epidemiology of Cardiovascular Diseases.” Chapter 51, In: Chronic
Diseases in Public Health. Lilienfeld AM, Gifford AJ, editors. (Baltimore,
MD. The Johns Hopkins Press, 1966).