The USPHS Heart Disease and Stroke Control Program
A few pioneers of, or around, CVD epidemiology were card-carrying epidemiologist-public health professionals, including Joseph Mountin, Herman Hilleboe, and James Watt. Their early recognition of the Epidemiological Transition, specifically the coronary epidemic, combined with traditional public health thinking about disease control, plus their status at the center of power in public health, had profound, wide, and specific consequences. For example, among them, they initiated CDC, the Framingham and the Albany Heart studies, the broad research agenda at the new National Heart Institute, and eventually, the national Heart Disease and Stroke Control Program.
Origins of the HDCP
We have the following fragments about the beginnings of the Heart Disease Control Program directly from an early, not the first, director of the program, Sam Fox, who was previously chief of the Cardiovascular Laboratory at the NIH Clinical Center:
“Somebody named Arnold . . . and I forget Arnold’s first name . . . apparently he was the first designated somebody that started what was located in the Bureau of State Services, or at least that’s where it was when I joined. How long it had been there I don’t know, but it was funded and was administratively part of NIH . . . when I moved there from being Assistant Director of the National Heart Institute (the Blood and Lung got added later).
The Heart Disease Control Program got its funding, as I understand it, from NIH, much to the distress of people like Bob Berliner and others who were not keen on Framingham and some of the programs that were competitive with the Intramural Program. And I can understand that. He was a basic scientist, Bob Berliner, and I respected him greatly …. But, anyway, when I moved to the Heart Disease Control Program shortly thereafter there was some “administrative clarification” in which we became part of the [USPHS] Bureau of State Services, which I greatly regretted because nobody in the academic world or the investigative world knew anything about, or gave a hoot for, the Bureau of State Services, although its function was obviously very important to try to put that which came from anybody’s research into practice” (Fox interview, 2001).
Sam Fox, the programs director from 1958 until its close, describes the small constituency that supported the USPHS Heart Disease and Stroke Control Program:
“As Director of the Heart Disease Control Program, when we wanted more money we would go to Elliot Corday, who was a cardiologist in Los Angeles, Cedars-Sinai …. A very worthwhile guy. But he was looked on as sort of a loose cannon by the traditional cardiological community because of some other things, not [for] his espousal of the Heart Disease Control Program. But he was of tremendous help to us in the coronary care effort and got big monies – six million or eight million for coronary care units and related ambulance services and things like that.
And we’d go to him and Mike DeBakey and Mary Lasker and … they were our message carriers to Congress and to the public. And it was very easy to turn Mike DeBakey and Mary Lasker on and they were long-time comfortable contacts with Jim Shannon at NIH and with other [high] places.
So we had our lines of communication well established well before I was even in Jim Watt’s office [at NHI]. Jim was very smart in that regard. Jim was a very important part of the Heart Disease Control Program. I think probably without his background in infectious disease epidemiology we never would have seen Framingham, never seen the Heart Disease Control Program as it became, with field stations like Missouri and San Francisco, and with CDC, the cholesterol [standardization] lab.
All those things, I think, if not very directly a product of the influence of Jim Watt were very closely tied to him.”
Bill Haskell provides further insights on origins of the HDCP in our interview with him:
“The Heart Disease and Stroke Control Program eventually was part of the Center for Disease Control in Washington and . . . really evolved out of the National Heart Institute. They [NIH] didn’t have the kind of unit to do interventions and training. The Heart Institutes National Program for Closed-Chest Cardiopulmonary Resuscitation first developed the films and contracted with people around the country to do the training. Then they took on the training of coronary care unit nurses when they came to the fore in the early to mid-60s, since those kinds of activities didn’t fit anywhere in the National Heart Institute at that time.”
Why Physical Activity?
The tie-in with the eventual program emphasis on physical activity originated with Sam Fox’s exposure to the ideas of Jerry Morris during a 1950s assignment to London. Fox early placed one of his young PHS officers in Thomas Cureton’s laboratory at the University of Illinois and that participation brought Jim Skinner and Bill Haskell into the picture; both working in that laboratory. Skinner was eventually recruited into the HDCP by Fox and sent to work on peripheral vascular disease at the University of Washington, while Haskell was recruited to Washington as consultant to the program for physical activity, then to head up Fox’s major undertaking, the Physical Activity and Ischemic Heart Disease Pilot Studies. Haskell became project officer for a planning committee chaired by Henry Taylor from the LPH at Minnesota.
This committee wrestled with the design and operation of a pilot study of physical activity and CVD prevention and over several years in the 1960s spawned a number of conceptual and methodological advancements in trial design and operation and in functional testing of fitness and the diagnosis of cardiac ischemia. The actual pilot studies were based at Minnesota. Wisconsin, and Penn State and they, too, had larger and unintended consequences (See Pilot Study).
Meanwhile, Fox established a laboratory at Georgetown University to look at protocols for exercise testing and other strategies in the early detection of ischemic heart disease. Haskell credits Fox, as follows:
“So, in the Heart Disease and Stroke Control Program, I really credit Sam Fox with pushing forward at the federal level on the issue of physical activity, particularly with cardiovascular disease. I mean, he kept that on the agenda when a lot of people had absolutely no interest” (Haskell interview, 2001).
Indeed, the HDCP sponsorship of conferences and studies and its publication of major reviews put the exercise issue at the forefront of the agenda of clinical cardiology, cardiac rehabilitation, and CVD prevention science. But the program, it seems, was ill-fated.
The Death of the HDCP
Haskell provides a version of the closing of the HDCP during the Nixon Administration:
“The whole Center for Chronic Disease Control was phased out starting in 1967-68, as there were general cut-backs. At the . . . time that CDC had been established and was growing there were a lot of questions about duplicate entities. You know, within the Centers for Disease Control there was a Cancer Control Program and there was the original Smoking Program (that was really for the preparation of the original Surgeon General’s Report on Smoking and Health, which came out of that unit). There was a Diabetes Program. Also there was a group that really pushed multi-phasic screening and that kind of health risk appraisals …. There also was an Office of International Affairs and a few others, like the large nutrition unit that Marge Zukel served in … and a Coronary Care Unit Training Program, and a program for training for CPR.
One of the other kinds of major activities [of HDCP] I had for a couple years was being the project officer for physicians who had military deferments to complete medical school and then came into the Public Health Service. There were so many of them in the late ‘60s because of the Vietnam War that most of them typically were assigned to Indian Health Services. But basically Indian Health Services got filled up and so Sam [Fox] took on a number of those individuals with the idea that this would be a great opportunity to seed them with established investigators looking at issues of physical activity. I was involved with about six to eight fellows assigned around and a number of them really continued with a career looking at related activities.
Thus, Smoking Program, Cancer, Diabetes, Cardiovascular Disease. And I think that with the economic downturn and looking for constraining government programs, the feeling was that there was duplication of [NIH] effort with CDC” (Ibid).
Fox provides a further note in what was an abrupt and brutal denouement of the HDCP:
“I didn’t tell you the mechanism of the demise of the program. My understanding, and this was second hand from people like Don Chapman who became a rear admiral in charge of the Bureau of State Services, who allowed as how . . . one of the directors of another program similar to the Heart Disease Control Program (now this is all second hand, but was related to me as being factual) got up at the American Cancer Society meeting and complained publicly that they weren’t getting enough money in the Cancer Control Program.
Now you don’t do that as a federal employee, [whether] commissioned corps, civil servant, or anybody else, as you probably well know. And this hit the papers as I understand it. And this fellow named Kelly, John or otherwise, I don’t know, was being charged by the Nixon Administration to cut back on health and welfare funding and he got all steamed up and … wanted to cut all the programs. But the Congress had just approved the Smoke House as we called it – smoking and health and the Kidney Program, which was supporting dialysis, two new, highly worthwhile programs.
So somebody said, ‘Hey, you can’t cut them. Congress just established them in the last couple of years.’ So they [the Cancer and Heart Programs] were, I guess, sent to CDC or maybe kept in the Bureau of State Services . . .
The Public Health Service had a real problem trying to get people relocated without essentially terminating their commission corps service, and likewise with civil servants. Many of them, I think most of them, went with Regional Medical Programs. But that was sort of rocky for a while.”
Jerry Stamler gives his brief account of how this active national program was abolished:
“They were liquidated with the stroke of a pen by Haldeman and Erhlichman for Nixon. Two Christian Scientists!
Some day that story needs to be written, how these programs were liquidated. I think they were told to close down within 30 or 60 days.
Sam Fox was beside himself to preserve the files and not let them get destroyed. I don’t know whether he was successful. The public rationale was ‘saving money.’”
Thus, the nation’s first program for the control of heart disease and stroke died a rapid and painful death. It was eventually resurrected in the state services programs of CDC and currently is incorporated in and under new and vigorous management with an ambitious international policy and action program of the CDC’s Division of Cardiovascular Health Policy and Research.
During its relatively short run, the national HDCP had wide consequences for CVD prevention:
- putting physical activity and exercise on the research and practice agenda
- approaching CVD causes and prevention using all major research methods
- advancing methods in activity and fitness measurement and cardiac diagnosis
- advancing trial design and operation, including the ‘faint-of-heart’ period to enhance adherence
- concluding that a trial of the independent role of exercise in prevention was infeasible
- bringing together thoughtful pioneers who proposed the concept and formal design for a multiple-risk-factor prevention trial
- training a sizable coterie of younger, bright investigators in CVD research careers
- establishing a government role in non-communicable disease control and prevention
Samuel Fox, in an interview recorded by Milton Nichamen, 20 May 2003, Maine, History of Cardiovascular Epidemiology Collection, University of Minnesota.
William Haskell, in an interview recorded by Henry Blackburn, 30 April 2001, History of Cardiovascular Epidemiology Collection, University of Minnesota.
Jeremiah Stamler, in an interview recorded by Darwin Labarthe, 9 August 2002, History of Cardiovascular Epidemiology Collection, University of Minnesota.
Labarthe, D.R., Biggers, A., Goff, D.C., and Houston, M. 2005. ‘Translating a plan into action: a Public Health Plan to Prevent Heart Disease and Stroke’. American Journal of Preventive Medicine 5:1, 146-51.