Milton Nichaman

Quotes

Charleston heart Study

Well, when I came down there, Ed had told Sam Fox and others that he really wanted to study differences in blacks and whites. Between blacks and whites on this island, because you know the Charleston blacks were quite different. You know the Gullah. He made the pitch that they were more closely related to West African blacks than they were to Chicago blacks. Which is in fact true genetically. They stayed right there, yeah.

I got down there and after playing a few practical jokes on me, like having a party and lacing my coffee with nicotinic acid and …..Ed’s idea was he’d get some blacks working in the hospital and compare them to whites working in the hospital. I didn’t even know what was the word “epidemiology.” I don’t think it had ever been mentioned to us in medical school. If it had, it passed me by. But I felt that something wasn’t quite right, you know? There was something wrong just taking a bunch of people from the hospital, even to my untutored mind. I said, “These are very different, these people.”

I met a very fine cardiologist by the name of Peter Gazes. You know Pete? Well, I had the good fortune of Peter Gazes suggesting to me that there was a young man at the University of North Carolina who might help me out a little bit. Bernie Greenberg. I went up and spoke to Bernie and he thought about it and said it sounded interesting and he would help me out. He asked me if we could get any information about the population distribution and maps of the city and other things or other ways that we might sample them. He knew all of those things. I was able because I was in the Public Health Service, to get a vehicle from the Air Force. I had to sign it out every week, but still they gave me a station wagon and I used it and we got some aerial photographs from the Air Force and Bernie sampled some blocks. Then in the blocks he had me cruising. In order to find out how many families we just counted water meters.

Then we had to knock on doors later to get to the people to recruit. Ed’s father gave us a 16-foot house trailer that we converted to an examination facility and we set up to do all sorts of things there. Ed was insistent that we had to do skin color determinations. We did reflectometry and took full-face photographs of all the participants and we measured lip width, nasal width, etc. Nothing ever got done with that data. Never ever, ever, ever. We did draw some blood, but once they found that there were some people south of Broad St. who had Negroid genes, that study went far away. That information was never going to see the light of day.

Julian Keil took over after Ed passed away. The second year we started collecting data and that went very, very well. I never really got involved in a lot of the analyses. That came a lot later. I recall one fascinating experience when going into the back country in Charleston County to a small black settlement. We had a black minister from town who came along with us to introduce us. We had to walk about two miles from where we parked our vehicle, so we took all our stuff with us. When we got there all the little kids were crowding around us, you know. I said to the minister, “What’s the matter.” He said, “You’re the first white person they’ve ever seen.” There were blacks living out in the rural areas that never saw a white man.

I did some clinical work during that time also in a lipid clinic that Ed ran. Wrote one paper. Went back with Herb Sauer and re-looked at a lot of death certificates of blacks and whites in Charleston County and did a lot of recoding, particularly in terms of stroke and cardiovascular disease. We published that paper finally. Herb would never agree that anything was ever, ever done. It just went on and on and on and on. But during that time I got interested in lipids and I said to myself that I’d like to work in this area. (6)

Heart Disease Control Program; NIHONSAN

…I was going to go to wherever the Public Health Service sent me at that point (1961). And they told me they were going to send me out to the Public Health Service hospital in San Francisco in what was called the Heart Disease Control Program Field Station. A fellow by the name of Paul Erlich was heading that up and I got out there in the hospital and Mack Smith was not interested in public health yet. He was Chief of Medicine and was a clinician in those days and started to set up a laboratory to support some of the studies that Paul was doing. . . And there were a couple of very well-known people who came to work for us at the field station. Gary Friedman was one and Darwin Labarthe. I was Chief at that time. Paul Erlich headed the international health unit and Len Syme came and then he went off to be a physician at Berkeley.

When he went then I became director of the field station. Darwin was there and Gary was there. I don’t remember the other person there. Steve Hulley worked for us then with Len Syme. These were some of the two-year people and they came through and stayed in the field and made contributions. I was at Seal Beach doing things and then got introduced to Stoney (Stallones) through Darwin, in part because Darwin was his student. That was a big joke, you know, he (Labarthe) was assigned to the field station but he was at the university doing his PhD work. Stoney was his advisor and he spent most of his time over at Berkeley and little of his time over at San Francisco.

And in 1964 when Nihonsan was being developed, Stoney was asked to make a trip to Japan to take a look at ABCC data. Then he came back to see what possibilities might be… Tavia Gordon … had already written I think the paper where he compared mortality rates [in Japan, Hawaii, and California]. And Stoney ran up against the ABCC in Hiroshima and saw this as a wonderful opportunity to get a cohort without having to go get a cohort, plus the fact that they were going to be doing all these total examinations basically forever. Then in 1964 he took me with him because the decision was made to set up a laboratory in San Francisco that would do the lipids for all three sets. At that time Stoney applied and got a grant to set up the San Francisco operation. But rather than a grant, Bill Zukel decided to put Abe Kagan in there [Hawaii] and have that as a field station of the NIH. You see one of the problems. It was directly supported by the NIH and I was funded for a laboratory to do the work and to coordinate the three operations.

So when we got to Japan the Japanese government was very, very leery of sending blood samples “out of the country.” You know. . . as xenophobic as they come. So we set up a system, set up a laboratory there with a good pathologist. That’s when I met Jean Tillotson. . . . with NIH in Honolulu and that’s where we started. So I was involved with them in collecting the dietary data. That’s the first time I got involved in collecting free-living dietary data. (10)

The “SAN” part of NIHONSAN

…this was 1964 when I got there and I stayed there for seven years. Three or four years into that period of time they had already collected some data in San Francisco and then the issue was following up the San Francisco cohort and they applied for renewal of the grant and it never got renewed. Stoney’s grant. So there was never any follow-up of the Japanese cohort in the San Francisco area. Stoney was bitter about that! There’s [still] no morbidity data from San Francisco. (12)

I went to [CDP] steering committee meetings. Now you and I – I have a memory of that period of time in San Francisco when, and maybe this is an erroneous memory, where you and I and Stoney and Darwin went up someplace on the California coast and we were discussing a multi-center kind of trial which in a sense got converted to MRFIT.

[ed. That was the JUMBO Trial. We recruited Jerry Stamler, Henry Taylor, and Richard Remington. Who did we recruit from the West Coast? Mack Smith!]

[It was JUMBO. I do remember putting it together and I was pleased to be a part of it. We recruited all sorts of people, Herb Benson, and then, of course, that went down the tubes when a 21-member site visit committee and no possibility of getting them together. Then the NIH “stole” it, [it became MRFIT.]

I remember hearing something then which I’ve kept in my mind all these years and you’ll probably tell me whether it’s true. At the end of CDP, before MRFIT and before the time JUMBO was turned down, Bill Zukel was purported to have said, “Never again. From now on (after CDP was finished) there would be no more investigator-initiated controlled trial things like this. We are going to control it at NIH.” Now whether there’s any truth to that I don’t know.

And CDP was such a success and . . . he wasn’t going to leave people like Jerry Stamler to take the future credit in the success. Look what happened with SHEP. They had to get Congress involved in order to get SHEP going and in the end they changed it to some new thing that they invented around that time – the collaborative agreement. (14)

The Current Scene

HB: And the current scene which is so bizarre. I’m not in it enough to know, but it seems to me that its focus on genetics is fine and it’s good, it’s solid, scholarly, academic work that must be done. But we’ve gotten away from population issues.

NM: But what people are hearing is that look, geneticists are going to figure it out and they’re going to replace this and they’re going to replace that and you can forget about everything else in public health.

HB: “We don’t have to bludgeon the whole population with lifestyle change,” they are saying. It’s a pipe dream in respect to attributable risk.

NM: It’s absolutely horrible and what worries me is that the idea that there’s some personal responsibility here, there’s no communal responsibility, or social responsibility! But they are promising the world and I think they’re going to flop. Geneticists have the answers to all of it. Even those that pay lip service to genetic-environmental interactions really believe that genetics is the real powerful thing. That’s what they believe.

“A Coalition of Like-minded Investigators”

HB: How would you restructure… the balance in NIH researches and their way of operating?

NM: You want pie in the sky? I think that there can be and there should be a small internal group concerned with smaller population studies. Just like there’s the clinical people who are doing clinical research and basic, biochemical research. And I think that ought to be very, very separate from… large population studies out in the general population. I think that the coalitions of like-minded investigators is far superior.

HB: That’s a wonderful way of way of saying it, “coalition of like-minded investigators.” We’ve got to get that back.

NM: A coalition of like-minded investigators. I mean, to me, and as population studies get more and more expensive in the name, as you said, and you said it very well, in the name of “fiscal responsibility,” they’ve just taken control of it completely.

HB: What should we do about nutrition, per se? I thought it would never get off the ground. It looked to me that Delta was going to re-do the Keys’ Equation with all the lipid subfractions and all our new knowledge about nutrition. And I didn’t understand what happened to it.

NM: I don’t understand what happened to it either.

HB: And I don’t understand why we don’t have a strong nutrition program with all the [good nutrition] people around NIH all these years.

NM: Because nutrition involves behavioral change in people. You can’t do it with a drug. As you said, the NCEP has been successful. They’ve been most successful on the drug side. They pay lip service so you won’t get up and scream at them. Look, Steve Blair – I’m on a new kick these days, it’s the fitness kick. I mean, Steve Blair has had this data out there for ages. It’s a powerful risk factor. It’s more powerful than blood pressure.

HB: And it extends over more diseases.

NM: It extends over more diseases, but it’s always at the tail end at NIH. I looked at the NCEP the other day. A friend of mine over in Israel wanted some information so I looked it up for him. They are still at that [level of thinking] if you have high blood pressure [or lipids] or if you’re a smoker you get drugs. (24)

Nutrients, Nutriceuticals, and Food!

They are taking these nutrients out of context, out of the milieu in which they are normally used. And basically, what they are doing is they are not treating foods. This is not nutrition any more, they are nutriceuticals. They are using it as a drug. So for them to do a study on, let’s say, beta carotene and say that, based on this study, beta carotene may be bad for some people or it sure doesn’t help people in what we thought and… relate it to beta carotene in a diet, I think that’s the wrong thing. I mean, that only holds for that pill that they gave those people and that pill was not a nutrient, it was drug. It was used like a drug. You know, Stoney [Stallones] once told me – coming back to Stoney – he said, “You in the nutrition field are never going to get any place as long as you keep talking about this “nutrient stuff.” You’ve got to get to where’s the constellation out there [ed. and he used to go like that, out there in the sky]?” I said, “I think we call that food patterns, Stoney.”

“I don’t give a s— what you call it. I see it as a constellation of things that we take into our bodies and what is the pattern?”

And don’t you really think that we have learned and I think we just read that in that one paragraph, don’t you think… and I hate the term “Mediterranean diet” because there’s so many of them – a diet that has in it moderate amounts of animal protein, lean, and fish and grains, particularly whole grains, vegetables, fruits, etc. That’s what we’re talking about. (30)