Zbynek Pisa
Year: May 29th, 2002
Location: Prague
Interviewed by: Blackburn, Henry
Abstract
Zbynek Pisa comes from the rigorous Czech school of clinical physiologists and became involved in prevention through the dealings of WHO with his famous chief, Jan Brod, and the need for a new CVD program in the European Office of WHO at Copenhagen. Once there and responsible, he got the idea of MI Registers from his consultant, Jerry Morris of London, and sold the program to WHO. This started a major thrust of CVD epidemiology and prevention in Europe, leading to many careers and eventually to the sweeping 10-year international program that Pisa subsequently developed when he replaced Fejfar at WHO central, Geneva, that is, the MONICA Project of CVD surveillance.
Pisa played central roles in WHO training programs for CVD epidemiology, coronary care units, cardiac rehabilitation, and CVD surveys and was major facilitator of the North Karelia Project, a community program in Finland.
We get some political insights here on the operation of WHO and its participant governments; not much anecdote, but a benign view of life by a fully retired man who once ran a major enterprise with vigor and perception. We finally can understand a little better the bitter treatment of its good people by the Eastern Bloc governments that arbitrarily sent and recalled their scientists to serve on international agencies and actually acquisitioned their hard currency salaries. (Henry Blackburn)
Quotes
The relationship between the WHO Center in Geneva and the Copenhagen Regional Office for Europe
It was very independent… at the inception, at least it used to be, I don’t know how it is now. But it used to be that the regional offices had their own programs, they had their own money, and therefore, they were pretty independent. There was quite a lot of jealously, of course, between the Regional offices and the Headquarters. So it depended really on the people who were in charge of the similar fields in Headquarters and in the Regional offices [whether] it somehow worked or if there was competition or jealously. So fortunately they had me with Fejfar and we were colleagues so we understood each other and so we had no problems. (9)
That was in 1963 when Fodor took the WHO Fellowship for learning something about epidemiology, because in our Institute it was the intention to start a research group on epidemiology in this country. And, of course… the group was founded and Fodor was named the Chief of the group, the clinicians were looking at it with great disrespect. Especially Widimsky was very much against and considered it can’t be any good, there’s no medicine, there’s no research, etc. Fodor got the fellowship and went for several months to study together with Bill Miall in Jamaica.
A few months later came a postcard from him addressed to Widimsky. On the postcard were nice sand beaches of Jamaica with the wonderful Caribbean blue. The wording of the postcard was, “Dear George, do you still think that epidemiology is nonsense? Yours, Fodor.” Widimsky, of course, did not laugh. (8)
Myocardial Infarction Registers lead to MONICA
The main contribution was by Jerry Morris who looked at it [ed. Pisa’s first tentative for a European program] and suggested the myocardial infarct registers, community registers. He didn’t call it like that, but in principle he stressed the importance of knowledge in the nature and history of myocardial infarction and in real statistics, that we really know… Population based, not hospital based because he realized and he knew that there is a big difference. So the program was somehow formulated and even somehow the funds which were needed. (12)
MI Registers Program
The program includes projects dealing with prevention of the disease, the improvement of mortality statistics, the collection of more and better information on the incidence of ischemic heart disease in the community, the assessment of the contribution of acute coronary care and different rehabilitation programs for patients who have suffered myocardial infarction. These projects are complemented by intensive training programs in epidemiology and statistics in coronary care and rehabilitation.
I can’t really complain because in principle, I could handle all these people. Sometimes it was difficult because even when considering the protocol, discussing the protocol and then the interpretation of their findings, it somehow didn’t comply fully with the protocol, incomplete data and so. But when they saw the others could do it they accepted it all right and they did it. It was really an incredible experience for me in management and coordination of this project. On the other side, I think the people learned quite a lot. That is practical training isn’t it? And, of course, the registers were really the basis for MONICA. (14)
MONICA was started by the Conference of ’78. The Decline Conference in Bethesda. I am convinced that we could never have started MONICA if we would not have had experience with the myocardial infarction registers. Of course, MONICA was the major contribution of WHO in that it lasted for 10 years and so many people were involved in it. And there were clinicians and they learned the epidemiological methods and they saw how you have to adhere to the protocol, which was agreed and approved, to compare the international data. This means [that] epidemiological thinking in the heads of clinicians became really foremost.
Fred Epstein told me that it [the Bethesda Decline Conference] was a great success and Jerry Stamler came and told him, “Look, something should be really known somehow the reasons for the divergent trends in the eastern European countries and some of the western countries.” At the time it was the U.S. even the western part of Europe had still an increasing trend. “Couldn’t there be a project to look at it and see, for example, to compare it, to look at the risk factors and the trends in those countries and to explain the divergence of the trends?” Jerry suggested, “Talk with Pisa. WHO might be interested in something like that. I don’t see anybody else to do it.”
So, I discussed it with Fred and I said, “Look, this is something which should last for 10 years and would really involve quite a lot of money and commitment. WHO cannot stop in five years time to support it.” So I had to discuss it with the Director General. At that time already he was somehow positive to cardiovascular diseases.
So I came to him and said, “Look, this is the idea coming from the Bethesda conference, this is how the trends in mortality look, and it would be very interesting and it might be possible to really to explain it. The other thing is, of course, when we start to work on it we’ll continue for 10 years so we might develop methods which might routinely be somehow introduced for routine surveillance of the cardiovascular diseases in the community and in the public health field. So there might be such side effects which might really improve the whole question of statistics, the task of vital statistics.” (17)
WHO Population Strategy of Prevention
The report in which you participated [1982 WHO Expert report on Primary Prevention of Coronary Heart Disease. A Population Strategy] got fantastic appraisal. It was presented as a first class report… and for the first time in my career at WHO even the Director General had read the report and… started to discuss it and comment on it. He stressed not only that the report brings some clinical problems to the community [but] shows that it is not just an individual problem, it is a community/public health problem and how it is presented and how it should be approached and so on. But [he] stressed the importance that this report was prepared and approved by top clinicians…” (31)
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