World Health Organization (WHO) Cardiovascular Disease Unit. 1959-1990

“The 1960s were indeed the golden age for research.” Z. Fejfar

As the first director of the World Health Organization’s Cardiovascular Diseases Unit, created in 1959, Czech cardiologist-physiologist Zdenek Fejfar had a unique vantage point from which to make that observation. In an unpublished historical account composed in 1974 shortly after he left the director’s post, Fejfar wrote that during the 1960s, the unit’s reach grew to include cooperative efforts among more than 100 institutes engaged in the study and control of cardiovascular diseases worldwide (Fejfar 1974).

The idea that WHO should become involved with “cardiovascular activity,” he wrote, was proposed by representatives of the Indian government in 1953. This was followed by a series of seminal WHO conferences yielding expert reports on atherosclerosis and ischemic heart disease (1955), classification of atherosclerotic lesions (1957), prevention of rheumatic fever (1958), and classification of hypertension and coronary heart disease for epidemiological studies (1959). But the CVD program was not formally adopted and funded until WHO’s World Health Assembly in Minneapolis in 1956, and it was March of 1959 before Fejfar finally was able to open the new CVD unit with a staff of two: himself and a secretary.

By the time of the new unit’s first scientific group meeting in 1959 in Geneva, Fejfar wrote, “epidemiology was considered important for international cooperation” (ibid.,1). James Watt, the U.S. NHI director, chaired this meeting–an indication of his active role in the worldwide as well as American development of CVD epidemiology. Members of this expert group, like those of all WHO consulting bodies, were called upon to look beyond their specialties and to address the functional role of WHO internationally, which was to recommend, help organize, and at times coordinate researches rather than to fund or direct them. ^[1]

Fejfar noted that among the CVD advisory group working to define the mission of the new unit, some members could not help championing researches related to their own interests. British cardiologist Paul Wood, for example, suggested specifically “that WHO should eventually include experimental research on the relation between atherosclerosis and blood lipids, and on the role of thrombogenic factors in atherogenesis and behaviour of the intima.” Fejfar concluded that, “We learnt rather quickly that having many good suggestions does not by itself ensure success” (ibid., 2).

Fejfar took responsibility for what he described as a slow start in the activities of his unit, writing, “I had no experience in international work or in epidemiology, and my knowledge about the distribution of major cardiovascular diseases was scanty” (ibid.,11). Of course, most researchers working in the field at the time had an equally shallow knowledge base, but Fejfar was the more eager to see that the methodology for measurement was developed. Just three weeks after assuming his post in Geneva, he attended the 1959 Princeton Conference, where, he wrote, “the deficiencies in survey methods were much evident. Apart from Ancel Keys’s Seven Countries Study, there was no experience of cooperative investigations nor other information about the prevalence of major cardiovascular diseases. When cooperative studies were undertaken, it became necessary for the participants to meet regularly to get to know each other and to improve the quality of their joint work” (ibid.).

Fejfar set as his first task the establishment of “a large circle of cooperating physicians and laboratories throughout the globe”–a network that would facilitate the dissemination of “available knowledge about the problems of cardiovascular diseases and about new developments by WHO.” Traditionally, he lamented, this knowledge had been contained in reports that were “more or less buried in ministries of health . . . only a few cardiologists knew of them” (ibid.2).

Consequently, Fejfar forged early a working relationship with the Geneva-based International Society of Cardiology (ISC), appointing a number of the group’s leading cardiologists to a WHO panel of experts. Their series of meetings during the first years of the CVD Unit outlined not only the methodology but “the main features as to how to treat and prevent major CVD,” But he wrote, “It became evident that publication of reports only, though written on advice of excellent experts, was insufficient. It was necessary to prove [in] pilot studies how to apply the knowledge in a given country” (ibid.,3).

He went on to insist that the operating modus of WHO would not conflict with regional medical organizations and customs. “Cooperation between outpatient and hospital services and the use of existing structures of health services were the two guiding principles. We never considered to establish special services for cardiac patients outside the local structure and organization of health care” (ibid.).

‘The world was our laboratory’

“In 1959,” Fejfar wrote, “we considered the globe a laboratory where one could find contrasting areas of cardiovascular disease prevalence. The opportunity was to relate the frequency of a disease with different ways of living and in different ethnic groups” (ibid.,4). He cited informal studies in places like Kampala, Singapore, and Fiji, for example, which had found that Indian immigrants in these areas apparently had higher morbidity and mortality from ischemic heart diseases than did the natives. The Seven Countries Study became one of the few to successfully carry out such cultural comparisons systematically.

The WHO CVD Unit early took on the coordinating function for a major international test of the cholesterol-lowering hypothesis, the WHO Cooperative Clofibrate Trial, based in the UK and in Prague. Although the study results were mixed–a reduction of non-fatal heart attacks but an increase in deaths from all causes in subjects taking clofibrate–Fejfar felt that the “emotional discussions” in medical journals and at conferences that followed the reporting of the negative trial results “overshadowed the beneficial effect of the drug and the valuable experience of how to conduct, coordinate and evaluate a large-scale preventive trial” (ibid.).

Throughout his tenure as unit chief, Fejfar believed in the original idea and uniqueness of WHO itself, an organization having no legislative authority and limited financial resources. It functioned effectively, nevertheless, by facilitating discussion, coordinating research, advancing methods and ideas, and forwarding projects under its informal international aegis. By 1972, he counted 131 institutes throughout the world that were cooperating with the WHO CVD Unit, including ten in Africa, twenty-two in North and South America, eleven in the Eastern Mediterranean region, seventy-two in the European region, three in Southeast Asia, and thirteen in the Western Pacific regìon. For the researchers engaged in a wide range of surveillance, prevention, and intervention activities in these far-flung sites, “it became customary to say and write ‘according to WHO classification (or standardization, or methodology),’” Fejfar wrote, adding that the CVD Unit “enjoyed excellent cooperation with cardiologists and other scientists all over the world. No one ever refused WHO invitations to come to give advice, write a paper or do a study,” (ibid., 9).

At a WHO meeting on worldwide cooperative efforts to control cardiovascular diseases, held in Geneva in 1973, epidemiologists and clinicians from nineteen countries evaluated the Unit’s fourteen years of work and outlined a program for the rest of the decade, which included “the establishment of nationwide community programmes for comprehensive control of cardiovascular diseases as distinct from a single disease control.” Fejfar wrote that the new WHO program would emphasize “early phases of cardiovascular diseases, some of which begin in childhood,” and on improvement of cardiovascular health “throughout the life span until old age” (Fejfar 1974, 7,8). These nascent ideas are included today within areas called “primordial prevention” and “life-course epidemiology.”

In 1973, at the peak of his international leadership, Fejfar was abruptly recalled to his home institute in Prague, with no explanation of the political reasons for his removal from the international scene. The Soviet-dominated Czech administration was known to take such autocratic actions in part because some Czech citizens had used their international assignments as vehicles for permanent emigration (defection), causing political embarrassment at home. Fejfar returned home without protest, later expressing regret only that he was unable to follow through with his dream of creating an International Institute similar to the WHO Cancer Research Institute in Lyon. Closing his report, he wrote, “The long-term programme I was prevented from building in later years remained only on paper” (ibid.11).

During the years after his return to the Czech Republic, even after freedom arrived in that country in the late 1980s, Fejfar remained low-key and devoted to his local cardiovascular community, writing books and editorials in Czech, and maintaining his international friendships. He appeared at the 1987 International Conference on Preventive Cardiology in Washington, D.C., but was no longer active on the international scene. He was gracious and generous in providing original documents and a fine collection of historic photographs for the University of Minnesota CVD History Archive (Fejfar 2002).

The WHO Europe Regional Office is established in Copenhagen, 1957.

The European Office of WHO was founded in 1957 and from its outset, under the direction of Zbenyk Pisa, actively developed community-based programs to study cardiovascular diseases. Its earliest effort was inspired by Jerry Morris, who, as consultant to the unit, decried the absence of valid data on incident coronary events. The pioneering Myocardial Infarction Register Program involved units in many countries involved in the “hot-pursuit” (active concurrent) surveillance of acute coronary events. Not only was much new knowledge gained about the nature of such events and the status of coronary care but also a coterie of younger researchers became experienced in the survey strategies of sample-size estimation, population enumeration and recruitment, hospital chart abstraction, and data management and analysis. Many early participants became leaders in subsequent epidemiological undertakings in Europe, including the massive WHO monitoring program MONICA of the 1980-90s.^[2](Henry Blackburn)

Sources:

Fejfar, Z. 1974. WHO Cardiovascular Diseases Unit 1959-1973: International cooperation in the fight with cardiovascular diseases. Manuscript. CVD History Archive, School of Public Health, Univ. of Minnesota.

Fejfar, Zdenek. 2002. Interview by Henry Blackburn. Audio recording. May 30. Prague, Czechoslovakia. CVD History Archive, School of Public Health, Univ. of Minnesota.*