Pierre Ducimetiere

Quotes

First, I may say that the possibility to make cardiovascular epidemiology in France at that time came from the meeting of the well-known Paris cardiologists with Professor Schwartz’s team (Inserm statistician], which was made up of statisticians at that time, but very happily the statisticians came to epidemiology as their major involvement and left biostatistics aside. So in the beginning of the ‘60s they [had] made Professor Lenegre head of the Cardiology Department of the Hospital Salpetriere which was the best known place in Paris for cardiology at that time. And Professor Schwartz made some risk surveys and began doing case-control studies with myocardial infarction and hospital controls at the clinics.

It was at that time that Professor Lenegre saw the importance of epidemiology and was involved in it. Jacques-Christian Richard was at that time a student of Professor Lenegre. He was trained in cardiovascular diseases and he was interested to do the job of the survey. So Jacques Christian was among the earliest cardiologists and he made up the questionnaires in this case-control. They had in mind that case-control study was not the best thing to go deeper into the epidemiology in France. But they knew about the Seven Countries Study too late and they would liked to have participated. So for that reason they said, “But we have to do something.” So they decided to launch a cohort study and this was a success story. . (2)

Paris Policemen

The idea [of the Paris Prospective Study] was to make a consortium between the scientists, cardiologists, and the epidemiology-statisticians, and also with the heads of health services of the District of Paris. This gave the possibility to use points in the city to examine people and to do the cohort study. The Town of Paris offered the possibility to use them. . . So the problem was to find the population. . .Very happily. . .the Town of Paris offered the possibility to look at its policemen. . . So it was decided at that time that the cohort study would be done in the clinical centers of the Town of Paris – free – and with the population of the Paris police. . .[For the policemen it was very nearly a representative sample. . . because they came and because they were easy to recruit and to follow. It is marvelous for epidemiologists to make surveys where people are obliged to participate. (3)

The Story Behind the French Paradox, from the Informed French View

It’s been annoying us for many years. . . but before we start talking about that it is, perhaps, important to note the question about the French Paradox was actually raised before the Paris Prospective Study was started and I remember from your lecture [in France in 1971] that perhaps the first remark on the French Paradox was made by Bronte Stewart in 1958. He had paid attention to some international comparison of coronary heart disease mortality studies of that time because that was the time when they started to become available and he had noticed that the French mortality rates were so much lower and yet it is known that the French diet is very rich and contains a lot of fat and etcetera. And Bronte Stewart in 1958 proposed that the protection of French might be due to their high consumption of olive oil.

[At that time he . . .still had the idea that atherosclerosis was an essential fatty acid deficiency. Sort of like a vitamin deficiency. So that would go along with the protection from olive oil.]

But interestingly, coming back to Professor Lenegre and his views, he said early that there is no such paradox. . .He said that’s a fallacy that French people have little arteriosclerosis and he didn’t believe the paradox. But it started to live its own life more or less and then another famous man in many respects, not that much in cardiology, but perhaps fighting against cardiovascular epidemiology, was John McMichael in 1979 also said that he didn’t believe that there would be a French Paradox.

We have a letter that appeared in the BMJ after the article of Bronte Stewart where Lenegre very shortly said that the reason why is that in France physicians cannot certify coronary disease if there is only the history of a heart attack. It is necessary to have more information than only the information about the heart attack. . . . he said that this is different with other countries where much more easily the physicians could sign the death certificate as coronary disease even though they don’t have all the information necessary for the diagnosis. He said that it is likely the reason that the rates are so low in France.

So this was forgotten until afterwards when we had the first incidence data in the Paris Prospective Study because we saw that effectively, and we had a paper making the comparison with the Seven Countries, which appeared in The Lancet in 1981, we showed that we had the average incidence of the European countries, as in the Seven Countries, but not as high as the American and Finnish.

You see what was thought paradoxical is that the rates of the disease are too low for such a magnificent French way of life – eating well, cooking with cream. This was the idea of the way the French people were eating. but there were not many data at the time and not even now, not scientifically proved about the content of the diet and the various nutrients. So the idea was that French people were eating a lot of saturated fat, and in my opinion that wasn’t true. But it is still the idea. So, how is it possible that this population has so low a rate?

So we had a paper in 1985 saying that this is strange because the data of the Paris Prospective Studies seem to show that our rates are definitely lower than those of Northern Europe. But France is not a country of Northern Europe. Most of the country lies more in the southern part of Europe. So if we want to prove something about the paradox it is not to say that we should have the same rates as the Finnish of the Northern European people, but that we [should] have the same levels that the southern populations, Italy, Spain, etc. So what I say [it] might be paradoxical if French people have lower rates than Spanish, than Italians, but it is not paradoxical that they have lower rates than the Finnish, of the Swedish, of the Norwegians, you see. So it is not exactly the same.

So what I say [it] might be paradoxical if French people have lower rates than Spanish, than Italians, but it is not paradoxical that they have lower rates than the Finnish, of the Swedish, of the Norwegians, you see. So what we think we demonstrated afterwards, with MONICA especially, is that our rates are the rates expected with the geography, with the geography and culture of Europe, and we haven’t rates lower than Italy or than Spanish rates.

Asked about a French north-south gradient in Coronary risk

Yes, within the country the same kind of gradient as in Europe. So it is not so important as a scientific discovery, but I think it puts the matter in the right place, The fact is people want to prove something that is important for wine makers, that France would be a different country because of wine consumption. Because it would have given the impression that in France they are protected. (13)