• Dedication to     Ancel Keys  • Introduction  • Overview  • Yugoslavia  • Italy  • Greece  • Finland  • Netherlands  • U.S.A.  • Japan     - Uskibuka  • Addendum

Ushibuka, Third Round, October, 1970

Ushibuka, the southernmost village on Kyushu, which is the southernmost island of Japan, was chosen by our Japanese colleagues as representative of a stable, rural culture predominantly of fisherman. It would serve as contrast to Tanushimaru, the farming community in the interior.

The fishermen of Ushibuka are a hardy lot, often at sea for as many as nine months of the year, their catch bought on the high seas by following fish tenders. We were advised that in October, a blustery cold month in the China Sea, most fishermen were home on leave with their families.

Arriving at Ushibuka by boat from Minimata across the bay, we were met by the local physician, Toseio Fukomoto, who spoke no English. His gestures and wonderfully kind face nevertheless helped us feel at home. He explained to me through a pleasant translator, his hospital nurse, that I would be living in the hospital and eating at his house.

I felt grand, as do all Westerners, in the presence of such kindness. It only proves unfortunate when we come to accept this hospitality as our due. The translator told me, aside, "I think I've heard, Professor Blackburn, that in addition to Dr. Fukomoto's usual household chef, he has laid on two assistant chefs for your visit!"

This concerned me. I had neglected to ask my Japanese academic colleagues, Toshima and Kimura, to prepare the way for me, as other colleagues in the Seven Countries around the world had figured out how to do long ago. I was neither "culinarily curious" nor "gregariously gourmet." I realized that I was trapped. For the successful conduct of our study in Japan, I would have to submit to Ushibuka hospitality in every regard.

Prior to arriving at the good doctor's home for our first dinner together, I took a stroll around the bay to look at the fishing boats tied up at the wharf and to see the cargos they had brought home for local markets. Exotic scenes and tantalizing aromas ranged from fishes to hawsers to the straw that packs the ice in the ships' holds, to tea, spices, and seaweed.

Stronger than these delights was the sickening odor of sewage. Nevertheless, the waters of the harbor were clear. I could see echinoderms, starfish and spiny sea urchins, fixed to the rocks below. But I knew the clarity of the water was misleading.

Far across the bay, we could see the peninsula of Minimata. Life magazine had just a few years earlier depicted on its cover a young woman victim of Minimata Disease - chronic mercury poisoning. Industrial toxins drained into the bay, built up in the food chain, and concentrated in the fish and seafood consumed so prominently by the Japanese. The taught skin around the victim's face; the drooling mouth; the scrawny, contracted limbs and distorted posture, forever fixed, worldwide, the image of industrial pollution.

West of Ushibuka Harbor, one could see the tiny island where the Portuguese established a trading foothold in 1600, built a church, and converted many islanders to Christianity. The church still stands as a memorial to the courage of those Japanese who, later, when the Portuguese were driven away, were challenged by their Samurai leader to stand on the symbol of Christ and swear they were not Christians. None of these devout new converts, according to legend, could desecrate the symbol. They all admitted their religious conviction and were carried off to their deaths.

Beyond the island, I watched the sun set over the Japan Sea, with red, purple, and lavender-scalloped clouds radiating in long tendrils, like some huge sea animal. The cries of sea birds, the beauty, and the centuries of tradition - all were inconsistent with my image of Minimata Disease and with the pervasive stench of Ushibuka Bay.

New Hazards in the Field: Sashimi

One hour later, a parboiled, pink, Western creature emerged from the 120-degree waters of Fukomoto's Japanese bath, clad in a lightly starched yukata (lounging robe), and feeling every bit the honored visiting American. We sat down together - Kimura, Toshima, Fukomoto and I - and the dinner service began. Fortunately for me, Fukomoto had a dining area allowing our feet to be placed comfortably on wooden racks below the table, so I didn't have to sit cross-legged. From the racks, a soft heat radiated, to take away the chill of a wintry day in the otherwise unheated house.

With fanfare, the rice-paper partitions opened and three impeccably clad chefs entered and laid before us the first course - purple, spiny sea urchins like those I had seen a short time before at the bottom of smelly Ushibuka Bay. Their tentacles were still moving. I was instructed to use a tiny spoon to dip into the shell of the living urchin and extract an orange granular substance, presumably the roe, and to transfer this mass to a small enamelware dish. This I was to mix with a spiced, highly salted seasoning, and eat. The delicacy was meant to prepare the palate for later courses.

Down it went. The first wave of nausea and apprehension swept over me. I tried to convince myself that my discomfort was psychological - that the chances of becoming ill, from an allergic or toxic reaction to the seafood or later from contaminants - were extremely remote. I should simply face the odds and take it like a man!

The second course arrived, presumably from the same foul bay. It was the largest lobster I have ever seen, resembling the Florida species without major claws but antennae well over a foot long. The head chef, in a deft motion with an incredibly sharp blade, sliced open the cartilaginous carapace and, with a simple gesture, pried and propped it open, exposing the jelly-like, translucent, uncooked flesh.

I assumed that lobster process sewage actively, not like oysters and clams, and that its meat was not likely to contain the source of pollution I had smelled. But having avoided sashimi so far, and having never before eaten a piece of raw fish or seafood, I felt overwhelmingly threatened. At the first bite, I broke out in a sweat, convinced that I was having a reaction. The lovely pink glow from the hot bath merged into a ghastly pallor.

Just at that moment, the nurse serving as my translator entered the dining room with effusive apologies and numerous curtsies, and knelt between me and my host. She explained to me, systematically, the dishes served and those coming up. Fortunately, subsequent dishes were baked or boiled. I made it through the meal without embarrassing myself, eventually retiring to my room in the hospital, where I did as much as I could to lose the exotic meal I had consumed.

The next morning, summoning the translator, I started with the long story of how, years before in Yugoslavia, I had become ill with Shigellosis, a form of typhoid, and had lost both good digestion and all lactose tolerance as a result of the severe dysentery.

I indicated that for survival I had been forced, over subsequent years, to bring much of my own food on field studies. I pleaded that I could eat only well-cooked, lightly seasoned fish, meat, and vegetables, with a little of the local beer or wine, and lots of rice. I explained earnestly that I understood the remarkable sacrifice my host had made to provide this hospitality. But I explained to her, as I could not explain to him directly, that unless he wanted me as a long-term patient in his hospital, a radical shift in the menu was indicated. I needed simple fare - vegetable or seafood tempura, or sukiyaki, boiled meats and vegetables.

The good doctor, whether or not he ever really understood, "got the message." He fired the two extra chefs and put on alternating meals of tempura and sukiyaki, along with desserts of canned Bartlett pears. This change allowed me a hard-working and delightful sojourn of several weeks on the southern island of Japan.

The Ushibuka survey concluded, the entire survey team stood in a row at the quai, waving to me at the rail of the ship. Long confetti streamers led from my heavy pink hands down to the delicate olive hands of our hosts on the wharf. I flirted with them by tugging various lines of confetti until the connected one giggled. Later I found in my stateroom the ultimate gift from Fukomoto: a new Seiko quartz watch!

Thirty-fifth Anniversary Conference of the Seven Countries Study, Fukuoka, October, 30, 1993

The Seven Countries Anniversary celebration arranged by Toshima and Koga was professionally and socially delightful, particularly the renewal of old friendships. Flaminio Fidanza refound his old "moniker" for me: "Enrico Il Nero," in contrast to Henry Taylor whom he called "Enrico Il Grande."

The scientific part of this celebration dealt mainly with the changes observed by the Seven Countries investigators in the lifestyles and disease experience of their regions over the decades since the original surveys. These changes are touched on in the several conclusions throughout this presentation and are treated in detail in a companion volume, Lessons for Science from the Seven Countries Study (Eds. H. Toshima, H. Koga, and H. Blackburn, Springer Verlag, Tokyo, 1995).

The social part of the conference honored Ancel Keys, approaching his ninetieth birthday. It included numerous post-prandial reminiscences by the Seven Countries colleagues. A few of these are reproduced here.

Srejko Nedeljkovic tells of life in Belgrade these days - many burglaries, and a large black market run by thugs. The whole of society is in upheaval in the former Yugoslavia. He felt fortunate to have made the trip, "escaping" through Budapest.

Alessandro Menotti reminisces about one of the Italian surveys: "In the mornings between 9:30 and 10:30 the electrocardiograms were terrible because of AC interference. After three days of this, we discovered that in the basement of our building was a kitchen. At that moment each day, the cook started an enormous potato-peeling machine, and the electrical fields created were disturbing the ECG recording. We had to call back the men who had been seen during those hours, because their records weren't readable at all by the Minnesota Code!"

"Another story started at the survey in Rome for the Italian Railroad Study. Our major consultant was Henry Taylor. In my family, he was called, "the American cowboy," because of his kind of casual fooling around. He stayed in a small pension. Every morning, I went to pick him up by car to take him to the hospital where the work was going on. During this period his wife was traveling in Denmark. She bought a new Volvo to take to the States, and drove it down to Rome. There the car was available to Henry Taylor, so one day I didn't have to go to take him to the hospital.

On that day, he didn't arrive for several hours. I called the pension to find out what happened. At the first bend, a curve to the right, he had crashed into the first car parked on the street. He had a lot of problems with insurance, and he didn't speak Italian. But the Volvo resisted very well; they are very strong cars. The next day, again, he didn't arrive. Again, he had crashed into another car at the same curve, at exactly the same place! The telephone calls for the insurance posed all kinds of problems. The third day, the same story. So I started picking him up again.

At the end of the survey, together with his wife (she drove), they took the Volvo to Rotterdam. They put the car on a ship and took a plane back to Minneapolis. There they waited for the ship to arrive in New York so they could pick up the car. Unfortunately, the ship sank in mid-Atlantic!"

Andy Dontas also reminisces. "In 1956, at a meeting of the American Heart Association in Chicago, Ancel Keys was already expounding his ideas about diet and heart disease. I approached him afterwards as I was about ready to return to Greece, and we had a long talk about possibilities for field research."

"You can't imagine the problems we had to face in the Crete pilot survey in 1957. It was just like going today to Nigeria or maybe to Nepal to do a study. Electricity was a big problem. No electricity anywhere on Crete except in Iraklion. There was no running water. There were no paved roads anyplace except in Iraklion.

In Corfu the next year the difficulties were more personal than physical because no participant could be convinced to be examined unless he got some kind of reward. So we had to examine his family as well, and do their electrocardiograms and everything, free of charge.

I think the best story of the Crete survey was when we walked down to the dock area where all the nice grapes were packed. Flaminio Fidanza was worrying all day how to pack the grapes he had bought, and so finally put them in his bathtub.

He was rooming with Kimura, who complained bitterly. One wanted to eat, the other to bathe! The prototypical Italian and Japanese."

Conclusions
	The Japanese cohorts share with the Greek Islands the lowest coronary heart disease risk of the Seven Countries, hinging the lower end of the regression line between risk variables and coronary heart disease incidence. The Japanese had the lowest fat and lowest saturated fatty acid dietary intake, and the lowest average serum cholesterol level. Despite a steep age rise in average blood pressure and widely prevalent cigarette smoking, the Japanese had the lowest coronary disease rates. The paradox is that their stroke rate is relatively higher than would be predicted by the Japanese configuration of blood pressure and other risk factors. This has led to the wider observation of a high prevalence of hypertension in other countries where there is the same high-salt, high-carbohydrate, low-fat, and low-protein traditional eating pattern. The findings in Japan have clarified the remarkable differences in population causes of the two major forms of stroke - brain infarction and atherosclerosis, and cerebral hemorrhage and hypertension. They have led also to an intensive re-examination of the causal versus confounding aspects of low blood cholesterol levels found in those who subsequently die of hemorrhagic stroke and non-cardiovascular disease deaths. These associations have now been extensively confirmed outside Japan. Most remarkable in the Japanese cohorts has been a dramatic change in risk characteristics over twenty years: a more than doubling of those with body mass index greater than twenty-six; a more than doubling in the sum of skinfolds; an increase followed since 1982 by a decrease in prevalence of hypertension; and a twenty-five percent increase in average serum cholesterol levels. All these are associated with a departure from the traditional Japanese diet and the significant automation of farming. There have been remarkable increases in protein intake - from eleven percent to sixteen percent - and in fat intake - from ten percent to twenty-two percent of daily calories. These lifestyle and risk-factor changes have been associated with a precipitous decline in hemorrhage stroke deaths - from about 4 per 1,000 per year to 0.3 per 1,000 per year, and generally attributed to Westernization of the eating pattern, while coronary disease mortality has not shown a significant increase in Japan. Our current hypotheses of the major population causes of coronary heart disease predict that an epidemic will arise when a threshold of mass exposure is reached and maintained for a decade or so, with average serum cholesterol levels above 200 mg./dl. This should come about soon, if current trends continue in Japan. But meanwhile, Japan has among the lowest cardiovascular and non-cardiovascular death rates, and the highest average life expectancy in the industrial world. Continued close surveillance is advisable, however, because of the increasing intake of saturated fatty acids and the continued high level of cigarette smoking. In fact, programs to prevent high risk in the first place are clearly indicated (WHO's "primordial prevention"). Certainly countries in rapid transition, particularly industrial nations such as Japan, present a fruitful opportunity for epidemiological research and for policy and programs in prevention of high risk in the first place.