Year: October 29th, 2010
Location: Letter from Egbart Dekker to Henry Blackburn
Interviewed by: Blackburn, Henry
Egbart Dekker, trained as an academic cardiologist, was a pioneer in preventive cardiology and a major force in the field for many years as director of the Netherlands Heart Foundation. In this letter, in lieu of an interview, he traces the course of activities in the Netherlands and Europe from the early 1970s to enhance population research and preventive trials, improve training in epidemiology, explore mechanisms of diet, lipids, and CVD, and to improve public health promotion. His role was central in all these activities and he gave much credit to his U.S. colleagues and to the American Heart Association. (Henry Blackburn).
Dear Henry Blackburn;
Professor Kromhout sent me your request for my “CV”. I am more than willing to try and be of support to your endeavor. First of all, Daan Kromhout and I had the impression that such a CV should be limited to an effort to contribute to the history of epidemiology in the Netherlands and cardiovascular epidemiology in particular as seen from my position as medical director of the Netherlands Heart Foundation.
Since, to my regret, I do not have any trace of a file from that period, the only data I can hope to serve you with are subjective in nature, a recollection with all the inevitable omissions and distortions of memory. To stress that subjectivity, I shall write it in the first instead of the third person singular.
During and after my training in internal medicine my research work mainly centered on experiments in the field of psychosomatic aspects of asthma and relevant aspects of tracheobronchial physiology. This is reflected in the publications from 1954 through 1962
During my specialization in cardiology and later in combination with its clinical practice the main interest was in the early application of pacemakers and in the electrophysiology of electrical stimulation of the human and canine heart. (Publications 1963 through 1971)
As a researcher and clinical cardiologist I became impressed by the large contribution of cardiovascular disease to total mortality. Part of this seemed avoidable by prevention and early recognition, surveillance and treatment. The individual clinician seemed powerless to change the national mortality rates. A position as medical director (1971-1986) of the Netherlands Heart Foundation (NHF) offered a chance to get things moving.
The NHF in 1971 had already chosen a series of targets: Prevention by public education concerning relevant life styles, Subsidising cardiovascular research, Promoting cardiac rehabilitation.
It seemed obvious from the start that medical science, epidemiology and the science of human nutrition had to be the scientific backbones of public education and other measures in the promotion of healthy life styles.
A major contribution came from that great example for heart foundations all over the world; the American Heart Association. The AHA gave me an opportunity to participate in a training course for its own employees during which one was made familiar with its manifold approaches. I visited Jeremiah Stamler and William B. Kannel and the Ancel Keys Laboratory at Gate 27, Memorial Stadium.
The findings of these three great men on a variety of risk factors and more specifically the famous Key’s Equation on the relation of saturated and unsaturated fats and cholesterol in the diet on blood cholesterol levels guided our public education efforts.
The stop-smoking message met with relatively little resistance from the profession, although in those days a sizable proportion of cardiologists and general practitioners continued to smoke, even in their practice. The dietary advice, however, was actively resisted both by the agrarian sector and by some members of the cardiological community.
Immediately after Professor Jo Hautvast was appointed to the chair of Human Nutrition in the Agricultural University of Wageningen, I offered support for his research in case he planned to direct his attention away from the local tradition of vitamin studies towards research in the cardiovascular field. This created a new scientific bridgehead in the midst of the agrarian community. In a series of well-designed studies, supported in part by the NHF, the results of Ancel Keys on the influence of dietary lipids on the human blood lipid spectrum were largely corroborated. My counterpart at the NHF, Jean Kierkels, then cleverly fed these results into the media as part of our public education campaign.
Another—monumental—support to our work came from O.S. Miettinen, then a rising star in the methods of epidemiology. He made a major contribution to the work of the heart foundation as an itinerant advisor throughout the episode of my work for the foundation. It soon became apparent that a sizable part of the applications for research grants submitted to the NHF were lacking in study design. This led to a major effort by the NHF to support the development of epidemiology on a national level. A series of summer courses in epidemiology were sponsored, in which Dr., later Professor Miettinen taught with great enthusiasm and intensity. The NHF made personal grants available for a one-year study in Harvard for a M.S. in epidemiology of which Miettinen’s lectures formed the backbone. We hosted one of the famous [Ten-day International Society of Cardiology Seminars in CVD epidemiology].
As it turned out, a good deal of the students came from the Department of Human Nutrition in Wageningen. I came to rely on Hautvast’s keen eye for quality in people. Frans Kok, for example, first worked for a number of years in the NHF as a supervisor of a group of our dieticians who gave hands-on public education in cooking for health. He was then sent to Boston for his MS in epidemiology. He now heads the combined departments of epidemiology and human nutrition of Wageningen University. Professor Daan Kromhout, well known as our national participant in Ancel Keys’ Seven Country Studies, was one of Miettinen’s students and so was I (1975-1976). Bert Hoffman and Jan Vandenbroucke who filled chairs of epidemiology in Rotterdam and Leiden were among those trained in Boston. It may be said that with support from the NHF, Miettinen almost single-handedly raised the level of epidemiology in this country.
As for me, the insight in the intricacies of study design and data analysis greatly helped in the proper allocation of research money. Economic power in scientific research sometimes tends to get monopolized with decreasing output for growing financial input. To invest in talented persons instead of ongoing plans may be refreshing. This led me to promote an additional established investigator program, again copied from the American Heart Association. One of the established investigators was Hautvast’s biochemist and later full professor Martijn Katan. He had analyzed for us the lipid constituents of a great many Dutch foodstuffs. He was also instrumental in a series of studies on nutrition and blood lipids in groups of volunteers. As an excellent, charismatic speaker he became a major player in public education, later warning against reliance on diets rich in carbohydrates.
Although less relevant for epidemiology, the NHF was also active in many other fields. A low-cost organization was build up that trained more than a million lay persons in cardiac resuscitation.
Together with the Dutch Cancer Society and The Netherlands Asthma Foundation we created and supported the foundation STIVORO for Smokefree Future.
The NHF had a separate council on cardiac rehabilitation, which gave guidance, information and support to the work floor, but remained largely unresponsive to my efforts to coax it into research efforts to measure efficacy.
The NHF was active in the international cooperation between European Heart Foundations, providing administrative support and venue for meetings.
Public education and a nationwide Association of Friends created a large familiarity with the NHF. This built an indispensable platform for fundraising. That allowed us to make a major contribution to financing research. The supervision and in part guidance of our grants, took a good part of my time. In the interest of impartiality I refrained from taking part in any research myself.
After my retirement I took great pleasure in returning to it. (references 1993-1999) My familiarity with epidemiology and with programming in Basic made it possible to support Dr. Verheul with a new program to estimate disease specific survival after cardiac surgery and to contribute to the data analysis of a series of survival studies, mostly after valvular surgery.
Invited by the faculty of the Free University of Amsterdam to a steering committee for the creation of a Research Institute for General Practice (EMGO) I tried to contribute to its methodological rigor by supporting the appointment of Professor Miettinen as its director. He once more laid the solid foundation to what is now a vital research organization.
In conclusion: my managerial function with the Netherlands Heart Foundation gave me an opportunity to contribute to the postponement of death from cardiovascular disease on a national scale that as a clinician I could not have dreamed of.
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