Lewis Kuller

Quotes

The hospital I trained in had a requirement that the residents working in the emergency room had to go out in the ambulance and ride in the back of it any time there was what was called a “coronary call” or “cardiac call.” That was in the late 1950s, early 1960s and I noticed as well as some of my colleagues, that most of the heart attack deaths were occurring outside the hospital.

Search for Variations

I teach my students that epidemiology is best when there’s chaos. We see right now that when you have an epidemic, it’s chaos… Epidemiologists such as Alex Langmuir talked about last night, that’s what he really focused on – epidemics, chaos. Chronic disease epidemiologists are the same way.

So, in essence, one of the things which I think is very important about epidemiology or what we need to do for the future is to make people recognize the fact that epidemiologists have to be out looking for where the epidemics are. And by that I mean where there are differences in rates of disease and keeping their eyes open and looking for unusual population distributions.

I think that modern epidemiologists do not understand that in many ways epidemiology functions by studying unusual distributions of disease. We do very, very poorly when we study homogeneous populations or those with stable rates. Our technique is not good then. It’s great for the physiologist and the biochemist, but it’s terrible for the epidemiologist.

I feel very strongly, for example, that nutrition is basically an experimental science in epidemiology. Either you study what are natural experiments, people who vary dramatically because of where they live or because of their social factors or their religious beliefs or something: vegetarians, people who have certain kinds of dietary habits, or people who live in unusual places, or we do it ourselves by manipulating the diet. Just counting and going out and measuring diet in large numbers of homogeneous people tells us almost nothing.

Up to now the glory that we thought that — and I wrote myself some years ago with Spielberg, and people keep kidding me about it—that we were in a genetic revolution, of understanding host susceptibility. It has not to this day, in all honesty, paid off very much for us. Except for Apo E. For any major disease we haven’t had a big winner. We’re beginning to recognize again that we have to study unusual populations, be they genetic isolates, be they people who have high rates of disease at a particular point.

To the epidemiologist genetics is going to give us a better way of measuring the host so that we can then study the environment and lifestyles better, and we can also then test some of our interventions perhaps in relationship to the genetics. But the likelihood that we’ll be able to describe the genotype for people who have high blood pressure and who should or shouldn’t swallow salt to my mind is a dream. Or as my Vice Chancellor tries to argue with me, that we’ll be able to tell which cigarette smoker is going to get lung cancer and everybody else can smoke!

[ed. They say, “So you do not have to bludgeon the whole population with changes in their behavior!”]

LK: And I think that’s far-fetched except at very, very extremes of the distributions.

Personal Observations

Of course, once you got attached to Abe [Lilienfeld] it was difficult to get unattached. Abe was very supportive. He knew of my interest in sudden death. Interestingly or not in my career at that time, Michael Oliver had come over to Hopkins on a sabbatical leave to work with Dick Ross in cardiology. And Michael Oliver was very interested and was also doing a study in Scotland on sudden death. So we got to know each other. Michael Oliver, although we know him for a lot of other strange things, had a real impact I think people don’t recognize, on American cardiology and especially on Dick Ross.

I think that supportive environment [at Hopkins] helped a lot of people. Because, to me, they were not only interested in epidemiology but they were interested in epidemiology as an advancement for their work in clinical medicine and in biology. So they early welcomed us as investigators and as peers and also gave us a strong underpinning of support in clinical medicine and biology, pathology and pathophysiology, which was very important to what we were doing. Abe also was probably the first person to recognize the importance of a multi-disciplinary approach. So he had economists, psychologists, social psychologists, biostatisticians, and nutritionists in the department. On the other hand, each person had their own expertise. So it wasn’t a matter of people dabbling. They were all super-experts.

Every one of us, I think, came into epidemiology because we were interested in preventing something. I wanted to prevent people from dropping dead and know why did they drop dead. That was the appeal to me. It was an interesting problem and I wasn’t going to solve it sitting on a ward in the hospital. It was quite obviously the real problem of coronary disease, not giving people nitroglycerin when they came in with angina, or doing EKGs every day on these people and seeing how their EKGs changed, or giving them some anticoagulants though they were good, obviously. The answer was basically in understanding how to prevent sudden death.

The ultimate measure of the success of epidemiology is what happens to the frequency of the disease in the population. Not how many p-values there are, or the confidence limits.