• Dedication to     Ancel Keys  • Introduction  • Overview  • Yugoslavia     - Dalmatia, Oct.     - Slovinai and more  • Italy  • Greece  • Finland  • Netherlands  • U.S.A.  • Japan  • Addendum

Slavonia, 1st Round 1958

October 28

The Slavonian region of Croatia is characterized by drab villages without centers, strung one-house deep along a two- to three-kilometer main street of pitted, slippery clay. These villages are surrounded by vast rich plains extending far into the Levantine mists. Monstrous black pigs snuffle along the roads, scattering before our jeep, grunting in dirty belches. The cattle herds are immense. Myriad fat geese surround us.

In fact, there is every evidence of great material richness here, but, as we learn, equally great spiritual poverty. The homes are unkempt, the water filthy. Hygiene is wretched; the folk obese and sodden, living under a constant downpour of rain (and slivovica). Stalin's genocide did not reach this far and the wealthy farmer, Kulak class persists here, with ingrained prejudice against orders of any sort, government of all sorts, and our taking their blood, in particular. We are told that the farmers here resent being 'guinea pigs.' A rumor going around says that once our dietary survey indicates their 'high' eating standards, their taxes will be increased. For these and other reasons, we have had a poor start in the town of Dalj. I wonder if this suspicious peasant independence may be exaggerated a bit by our urbane, upper class Zagreb colleagues.

October 29

Today in Dalj we broke our backs examining forty-three participants. None was drunk, and the sun was shining. The electrocardiograph machine that I recently carried all the way to Paris for repairs is still unstable, but seems to be improving. We sense, nevertheless, that disaster lurks every morning as we turn on the machines. Careful calculations of the amounts of electrode paste and paper rolls suggest that we will make it, barely, through the survey.

The fog today is heavy and wet. The mud and filth, the screeching geese and grunting pigs and rattling wagons, the ruddy peasants and their rustic wives in patched trousers, all recall the coarse peasantry of Brueghel's paintings. On sunny days we have a particularly poor response and overall we have, so far, a low response rate here. This week, it appears that a nearby market fair has reduced us to a trickle of twenty-seven participants per day.

On the positive side, we are blessed with marvelous electrocardiographic technicians here, medical students I know only as Sabina and Velika, who are competent, hardworking, uncomplaining and, more important for me, non-singing! The pop song, 'Di pinto di bleu,' still rings in my ears from the incessantly singing technicians in Dalmatia. The Dalmatian cardiograms are now all mounted and I am plowing through their initial coding at the rate of forty to fifty per hour.

November 3

Despite the many problems, we have finished the survey in Slavonia with only one eligible participant missing. He is apparently at sea. Two myocardial infarct patients were identified by electrocardiogram. We had a wonderful time with Pentti Rautaharju, who works carefully and effectively and will soon come to Minneapolis, where we will finish work on our electrocardiographic coding system.

The Serbian operation under Professor Djordjevic' began in 1962, at Velika Krsna (Black Cross), and profited immensely from the earlier Croatian survey experience, the participation of Srejko Nedeljkovic' in prior surveys, and the effective coordination and sharing of skilled staff. Thomas Strasser supervised and carried out much of the laboratory data collection, and, in 1965, came to Minnesota to develop the Serbian data for analysis and publication. Bozidar Simic', pioneering nutritionist, carried out the diet surveys and food analyses. I directed the electrocardiographic station and was amazed to have to instruct the men, ages forty to sixty, how to ride the bicycle ergometer. They were as likely to pedal backward as forward. It was only after being reminded of the status of the roads connecting Velika Krsna with its neighbors that I realized these men had never used bicycles in their lives.

The Serbian surveys went so expeditiously that my journals lapsed during this period. I recall, however, that our team enjoyed going back in history on a visit to Topola-Oplenac, the historical repository of the Karadjordjevic' monarchy and the tomb of the last Yugoslavian king, Alexander, killed in Marseilles in 1934.

Croatia, Second Round, 1963

September 25

Today Pentti and I departed Munich in great spirits, navigating by Volkswagen van the Gross Glocknerstrasse and traveling down through Slovenia to the Adriatic coast.

The famous coastal road, described earlier as renovated by Napoleon 150 years before, is now sealed off for construction of a grand sweeping highway to Dubrovnik.

We are repeatedly forced onto detours through Bosnia-Herzegovina (the scene in 1995 of villages decimated by civil war). It is a barren moonscape with miserable terraced fields, scraggly orchards and vineyards, and dark, furtive children, dogs, and goats everywhere.

Poised on the cliff of the plateau above the Adriatic, we looked down at coastal towns far below, and at the shimmering sun on a magnificent sea, with the lovely blue arc of an archipelago on the horizon. At dusk we reached the coast at Sibenik, arriving during a grand naval gala. The entire Yugoslavian fleet was in port with its uniformed crews perambulating gaily on shore leave. We felt part of a Gilbert and Sullivan operetta.

The second round Seven Countries survey in Dalmatia in 1963 was accompanied by much social palaver, high-tech add-ons, and a great deal of staff enthusiasm and collegiality. The Research Committee of the International Society of Cardiology was at the acme of its influence, with Keys and White in charge. The leaders had arranged a meeting of dignitaries from around the world at our survey center in Makarska to produce a broad-ranging report with recommendations for needed cardiovascular disease research.

This added greatly to a sense of significance and to the festive and collegial spirit of the repeat survey in Dalmatia. The Makarska Conference of the international group culminated in a successful report, with only one hitch (described later in The Healing Power of Jazz).

This second survey round, I was determined to avoid illness and went through elaborate preparations, importing corn flakes, condensed milk and canned goods to last the duration, carried in our packed Volkswagen mini van rented in Munich. There, Rautaharju and I met his graduate bio engineering student, Hans Friedrich, engaged to prepare the high-tech electrocardiographic and other recordings being added systematically to Seven Countries field surveys.

The team works efficiently on this second-round survey. The young medical students are stimulated by proximity to grand cardiologists. The staff are of many ethnic origins, and our evenings are spent in medical discussions, pleasant dinners, endless toasts, and late-night dancing.

Despite the problems of power outages and difficult transport along the coast - the usual hazards of working in Yugoslavia - things are going well. I managed to disguise my gastro-intestinal susceptibilities, until finally forced to eat anchovy and hard-boiled egg sandwiches, washed down with slivovica, with the mayors of each new village as we moved down the coast. This reduced my enthusiasm for the work that had to go on!

Slavonia, Second Round, 1963

October 15

Even the packing in Dalmatia and the transport to Slavonia seemed happier and sunnier in 1963 than in 1958. But now, on the Hungarian border, the mists roll in again. Ox-drawn carts lumber across rich, green fields against darkly wooded backdrops reminiscent of scenes from Doctor Zhivago. Again, we live and move in swirls of mud. Our participants, their harvest complete, become progressively dissolute, foul-smelling and lice ridden, eventually affecting our own spirits and health.

But there are a few bright spots here in Slavonia. We see nests of great, dignified storks in abandoned church steeples. Our country inn offers lunch of 'Fishpaprika' from a huge caldron, in which grease and paprika float on the surface while clumps of catfish bones and meat and tuberous vegetables protrude. We relish this spicy fish stew, served over grayish hunks of the local peasant bread.

At the confluence of the Donau and Drava, two great rivers of central Europe, we watched fishermen dock today during mid-day break. Smiling toothlessly, they held up their catch proudly for us to admire: wriggling, hammer-headed river catfish, magnificent, fifty-pound beasts of the deep.

Despite every precaution, I have again become ill. In my hotel room in Osijek, I am worse each night, with fever, chills, and dysentery, subsisting on the local mineral water - foul-tasting, bitter stuff. Desperate this morning, I happened to read the tiny print on the bottle label and realized I have been treating myself daily with several liters of a mild solution of Epsom Salts! Each liter contains nearly a gram of magnesium sulfate; hardly the best strategy for dysentery.

Again, I leave the field from Slavonia in a special rail car to Belgrade, then by a first-class Wagons Lits compartment to Munich, where I will find the cleanliness, calm, and care of the West.

Conclusion
	The baptism by fire of the survey teams in the field was a dramatic and useful contribution of the Dalmatian component of the Seven Countries Study in Yugoslavia. This 1958 experience was crucial to all subsequent activities of the study: the methods, procedures, training, and attitudes and strategies were tested for carrying out difficult field operations. Moreover, Buzina's nutrition field work in Yugoslavia was central to determining the contrasting populations examined in Dalmatia, Slavonia, and Serbia, greatly enriching the outcome of the study overall. Buzina's international role in nutrition has strengthened the Seven Countries Study from the outset. Clearly, his initial hypothesis about animal versus vegetable fat was a pioneering concept which has been confirmed widely as having a central role in atherogenesis. In Yugoslavia, the diet measurement strategy provided the basis for precise ecologic correlations of diet and disease in the Seven Countries Study and other studies internationally. Buzina's skillful organization was also responsible in part for meetings that have profoundly affected the course of cardiovascular disease epidemiology and prevention. The first was the 1963 Dalmatian meeting of the Research Committee of the International Society of Cardiology. At this meeting the subsequent research of that organization was born, as was its organization along lines of Scientific Councils. The 1968 Makarska Conference involved the International Society of Cardiology, the World Health Organization, and the National Institutes of Health of the United States. Its recommendations profoundly influenced subsequent generations of preventive trials and community-based studies. In addition, the first International Ten-day Training Seminar in Cardiovascular Disease Epidemiology was held during that 1968 Dalmatia survey, and this seminar has become one of the more effective training programs in the field. Buzina has continued in his official capacity with WHO to provide broad overviews of Mediterranean dietary patterns and health issues. The work in Serbia with principal colleagues Djordjevic' and Nedeljkovic' has provided the modern demonstration of the effects of rapid changes in population risk characteristics on subsequent disease experience. Serbia has had a phenomenally increasing coronary heart disease rate, at least up until the recent civil war