Leon Epstein

Quotes

Community Health Study and CHAD

And when I came back [from the Blessington 10-day seminar] Sidney Kark was very interested in beginning to utilize the data from the Total Community Health Study in planning an intervention program for cardiovascular disease. And basically that fell into the totality of [his] concept of community-oriented primary care. . . .And basically what Sidney wanted to develop was a program built into a primary health care framework. . And that became . . . What we call finally the CHAD Program which is “community center for hypertension, atherosclerosis and diabetes.”

The program began in 1970 when we began to have the first people who completed their examinations in the Community Health Study. We identified those people who we could define as borderline and high risk in relationship to cholesterol, hypertension, smoking, physical activity. We developed on the basis of that individually oriented programs for high and moderate risk people and attempted to develop for people who were not at risk a general health education program to prevent the development of risk.. . . This was a drug-free cholesterol program, if I could call it that. It was diet, hypertension – yes. We had a definite protocol for hypertension. We tried to get people not to begin smoking.

This program went on for 25 years. . . It wasn’t a randomized study. We took a contiguous area to the population served by the health center and both those populations reported 12,000 people who were in the Community Health Study. And we compared them at the baseline and . . . At 5, 10, 15, and 24 years down the road. Five and 10 years were on the basis of actually examining the people. The later studies were in relationship to mortality data because there wasn’t the funding to re-examine everybody.

Mostly what I think was shown over the years was that the major impact was on hypertension and smoking. The impact on obesity was minimal if anything. The impact on cholesterol levels was also. . .now this was pre-statins, so impact on cholesterol was also minimal. An interesting thing was that after . . 15 years, we managed to show a shift to the left on the blood pressure curves in the population, which we found to be interesting.

. . .The concept was that a community health program is going to be built into it as part of a primary health care framework. This is Sidney Kark’s basic concept that he brought from South Africa originally. . . That that was the way to go about improving the health status of populations and that was the basis of what he called “community-oriented primary care.” Inherent with this was a major program in child health; there was a major program in maternal health; there were programs in infectious diseases; there were programs in long term care of disabled, elderly. So this was all part of a framework in a defined community and with very definite impact in child health, infant health. . . Much of this found its way afterwards into the health services of the country basically. . .The cardiovascular framework was central, but not the only one and I think this should be stressed because it was part of [a] total community look at health. (3)

So that was when I left here in 1975 and three years later published the first data on the beginning of the fall in coronary disease mortality in the country. I remember Michael Davis asked me to do this study and when we produced it he said, “Well, we can’t really talk about this. Nobody is going to believe us that coronary mortality is falling.” (5)

The interesting thing we found was something that I think we knew but we never managed to look at really was that the highest levels of coronary and cardiovascular mortality in the country were in North Africans, both in men and women. And this had happened over a 15-year period after they came to the country. I’ve always said that this is one of the greatest public health failures of this country was the fact that we didn’t prevent the cardiovascular disease change in the North African population. We missed it with the Yemenites, but we should have been ready for the North Africans and we weren’t. What we found also was. . . That the mortality from cardiovascular disease from stroke in women in this country was higher than that for men. At that point in time there were only two other references in the literature to higher female mortality. One was in Wales and the other one was in New Zealand.

This interested us, this was mortality so we got a grant from the chief scientist here in this county and did a study . . In the north of the country in which we looked at several vascular disease mortality and case fatality [rates] especially. And there were some very interesting findings that came out of that showing the differences between the different ethnic groups and the tremendous importance of case fatality in the North African population at that point in time. I’m talking about it’s the beginning of the Eighties actually.

In 1990 I came back here to Jerusalem. I think the question that I always ask myself is “what have we done with all of this?” There is a national hypertension program. . .(6)

I think that one of the directions we should be moving in, and it’s difficult because the doctors object to it, is to ask ourselves, “What is the role of the other health professionals? What is the role of totally non-health frameworks?” One of the interesting developments at the present moment is in the field of the role of the city in which you live. What is the role of other agencies in the whole question of health promotion and disease prevention? They probably have a greater role, a greater impact in many ways than health care has got without going back to McKuen and some of those things we’ve been talking about.

It’s been a number of years since I’ve really been involved in epidemiological research in cardiovascular disease. I’ve become far more interested in what can be done at the grassroots level. And one of the questions I think is …… Sidney Kark developed the ideas of community-oriented primary care. . .I think the question that needs to be faced at the present moment is even more than it was 15-20-30 years ago – we’ve been talking about it for all that time – is what are the means by which the knowledge we have on risk factors can be brought to bear on – which is largely behavioral in the population? I must say that I don’t think the answer is in the medical model. I’m not for one moment saying that the basic epidemiological data going down to the molecular, genetic, is not very important. It’s critical. But the question is how is this going to be utilized? How is this going to be built into the framework? And I think that this is something, talking for this country, I think that we haven’t really begun to ask many of the questions. (10)

I may be wrong, I don’t think we really understand enough about the process in the United States by which smoking became socially unacceptable. And I think that a lot of the research that needs to be done may not be epi research in cardiovascular disease but is going to be in societal functioning. It’s going to be in how people make decisions. . . We don’t know enough about that interface. We don’t know enough about the pros and cons, the different weight that people, that individuals and families and communities give to different aspects of their lifestyles. And I think that these are some of the questions that I feel are going to become critical in next few years. And it’s not only related to cardiovascular disease. It’s related to many, many aspects of major health questions, major health problems. (14)