(Circulation. 1995;91:1253-1262.)
© 1995 American Heart Association, Inc.
Articles |
History of the Council on Epidemiology and Prevention, American Heart Association
The Pursuit of Epidemiology Within the American Heart Association: Prehistory and Early Organization
From the Division of Epidemiology (H.B.), School of Public Health, University of Minnesota (Minneapolis); and the Institute of Social and Preventive Medicine (F.H.E.), University of Zurich, Switzerland.
Correspondence to Henry Blackburn, MD, 1300 S Second St, Suite 300, Minneapolis, MN 55454.
Key Words: epidemiology • prevention
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Introduction |
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We present a brief history of the Council on Epidemiology and Prevention of the American Heart Association (AHA), one of 14 such scientific councils. It is based on a review of documents in the AHA archives at the National Center in Dallas, Tex, and on our personal experience dating back to predecessor organizations of the council. We recount in particular the early difficulties in getting acceptance of the idea of the new council. Then, we encapsulate the scientific and organizational issues and events that occupied the founders and members in the formation and subsequent activities of the council. Finally, we assess the principal contributions of the council to cardiovascular medicine and to the public health; these include stimulation of the field by annual scientific conferences, directed research, and the development of methods. The council interacts widely within the AHA nationally as well as with the National Heart, Lung, and Blood Institute (NHLBI); World Health Organization (WHO); International Society and Federation of Cardiology; The Society of Preventive Cardiology; and The American College of Cardiology. The council also has been an advocate for preventive practice and public health policy.
Cardiovascular disease (CVD) epidemiology is a relatively new field of scientific endeavor that developed with the growing burden of disease among western industrial countries following World War II. CVD epidemiology was initiated in a unique manner—not by "epidemiologists" but rather by clinicians and laboratory scientists who were most familiar with the manifestations and mechanisms of these diseases. These investigators became epidemiologists to satisfy their curiosity about the changing frequency and associations of coronary heart disease (CHD) in the population. Their questions and the need for sound methods brought them together. Organizations were then formed to forward their work, and the organization central to development of CVD epidemiology in the United States was the AHA through its scientific councils.
However, realization of a formal AHA Council on Epidemiology and Prevention was neither easy nor simple. We include our experience with earliest activities in the field and a systematic review of minutes and reports from the AHA archives.
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"A Tortuous Gestation" |
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"The Council had a rather tortuous gestation that lasted three and a half years from the date of conception," according to the council's first historian, AHA staff member Leonard Cook, in November 1965.1 We use the analogy of a long, upstream journey requiring 15 years, during which many bends and shoals were encountered. The vessel for this long voyage was the AHA Scientific Council on Community Service and Education, in particular, its Committee on Epidemiological Studies and its Committee on Criteria and Methods. Members of the Council on Arteriosclerosis worked concurrently to introduce epidemiology into the concepts and structures of the AHA. We trace this tortuous journey, beginning with the AHA and its scientific councils, to the successful arrival in 1964 of the AHA Council on Epidemiology and Prevention.
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Brief History of the AHA and Its Scientific Councils |
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The AHA was originally formed in 1924 as a "club" of cardiologists who were members of the American Medical Association. It was a direct outcome of actions by leading cardiologists who over a number of years founded local "associations for the prevention and relief of heart disease."2 The AHA grew, in the words of first president Lewis Connor, from "the very wide great interest in circulatory diseases," a result of "truly revolutionary advances in the diagnosis and management of heart disease."3 It focused on "collecting, disseminating, and applying knowledge about the causes, prevention and treatment of heart disease" and was particularly active in the field of cardiac rehabilitation.
From the outset, according to a founder, Howard Sprague, tension developed in the AHA between "the expansionists [who] favor the public health, public education, lay representation, federal and large scale features of the program, and the contractionists [who] desire the emphasis on the small, strictly scientific, professional clinical aspects of the Association."3
The result of a white paper by Sprague and his committee on policy was that the AHA transformed in 1948 from a professional society into a public voluntary health organization. The founding fathers of this new structure established the Scientific Council to deal with scientific matters while the association operated more broadly among the public. The functions of the Scientific Council were to review and support research in CVD, plan the annual scientific program, and carry out professional education. The council was to be the part of the AHA where those interested in heart diseases would be most effective and most "at home."
The "council" became the "scientific councils" in 1954, when, in swift order, councils were established on arteriosclerosis, on rheumatic fever and congenital heart disease, on circulation and high blood pressure research, on clinical cardiology, on basic science, and on cardiovascular surgery. It was recommended that "the door be left open" for other scientific councils to be developed. The original founders of the AHA Scientific Council stated, "Whenever the purposes of the Scientific Council can best be served by the establishment of a new constituent Council, representing specialized parts of its interests, this may be done, subject to approval of the Scientific Council at its Annual meeting or at a special meeting called for this purpose, and by the Board of Directors of the AHA."4
The different views of members of the Scientific Councils became clearly manifest between those with mainly academic and clinical interests and those with a community orientation. This became particularly evident with the proposal for a Council on Community Services and Education. Some in the AHA were concerned that productivity of the councils might be interfered with by dilution of AHA resources. They were especially wary of the proposed council's interest in a "different audience," that is, the public. A few AHA leaders, nevertheless, defended the idea that "community service is just as professional as research and to try to divide them is purely artificial."4
One does not have to read between the lines of AHA documentation over the years to comprehend the great effort required to move forward these activities. Nor is it difficult to detect the postures of those who resisted change in the AHA as an invasion of their narrow specialty interests and as a diversion of resources toward the community and away from research. This protectionism contrasted to others' broad vision of the councils' many functions and strong appeal and of the overall importance of the councils to all public as well as scientific activities of the AHA. Those imbued with the wider vision set the precedents and built on them the steps needed in further AHA organization. Nevertheless, the pain of transition between a visionary idea and a viable organization is everywhere evident in the long history of the AHA and its scientific councils,1 2 3 4 5 especially in the establishment of the Council on Epidemiology and Prevention.
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Prehistory |
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Based on our early participation, we suggest that the true origin of the AHA Council on Epidemiology and Prevention lies in the investigators and their questions, in particular, with their early need for epidemiological study methods. We found that a major force toward organization among the early CVD investigators was a desire to share ideas, improve methods, and stimulate research in this new field. Population studies of CVD and its risk characteristics were under way independently in the late 1940s and early 1950s in several US study centers, including Framingham, Minneapolis, Albany, and Los Angeles. These were directed by clinicians and investigators who were highly skilled in areas other than epidemiology and statistics. Curious about the frequency and associations of CVD outside the clinic although mainly involved in the clinical aspects or mechanisms of atherosclerosis and hypertension, they were often frustrated by unfamiliarity with the design and methods of surveys. These inadequacies were reflected in the earliest meetings and formal activities of the investigators, indicating to us that it was as much the need for criteria and methods for their new science that brought them together as it was the scientific issues.
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AHA Council on Community Service and Education |
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Soon after the AHA became a public voluntary organization in 1948, the AHA Section on Public Health became the Council on Community Service and Education and promptly established a research study committee, under the chairmanship first of Paul Dudley White, next of Ancel Keys, and then of Herman Hilleboe. Its functions were to review grant applications and make recommendations for support of epidemiological studies within the national research budget of the AHA and to stimulate and review studies involving AHA programs and methods.
In collaboration with the new National Heart Institute (NHI), this committee promptly organized a series of crucial meetings on CVD epidemiological concepts and methods, which were held in succession at the Arden House Conference in 1956; the Brookline Conference, in 1957; and the Princeton Conference in 1959. These conferences in turn became major stimuli to further AHA activity and organization around epidemiological interests. The Council on Community Service and Education established in 1958 a Committee on Epidemiological Studies to forward the overall activities of its epidemiologist members, retaining the research study committee for its review and methods functions.
In terms of the organization, the January 1960 meeting of the Committee on Epidemiological Studies was especially significant in council history. A thorough review of the status of CVD epidemiology was made by Chairman Oglesby Paul and by AHA Medical Director George Wakerlin, establishing its precedents in the early AHA Department of Public Health. They proposed council status, indicating that from its inception the AHA had "included individuals interested in public health and epidemiology. . . ."6
The committee then reviewed the Princeton Conference Report and took up the conference recommendations, appointing a subcommittee to implement them, with Frederick Epstein as chairperson.7 8 Immediately after this meeting, Oglesby Paul convened the first Conference on CVD Epidemiology; it was held in fall 1960 in Chicago and had a program on the nondietary aspects of CVD risk.
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The Tortuous Gestation Is Conceived |
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The next highlight in the history that led to establishment of the council was the following motion from the January 1961 meeting: "that the Executive Committee of the Council on Community Service and Education be informed that this Committee [the Committee on Epidemiological Studies] favors the creation of a new Council on Cardiovascular Epidemiology and a Cardiovascular Society, the exact name and form to be determined later." This proposal for a council and for a society of epidemiologists, within or outside the AHA, was moved and carried and was the formal beginning of activation toward AHA council status for epidemiology.9
The motion was subsequently acted on in a landmark memorandum from Felix Moore, chairman of the Committee on Epidemiological Studies, and Oglesby Paul, president of the AHA, to the executive committees of all AHA Scientific Councils, dated March 22, 1961. The following is an excerpt:
Re: Creation of a Council on Cardiovascular Epidemiology
The primary objective of such a Council would be to provide a place within the American Heart Association structure for those professional groups concerned with the study of populations; such professionals as physicians, epidemiologists, statisticians, social scientists, sociologists, physical and social anthropologists, psychologists and geneticists. It would also provide a place for persons who have a major interest in some other Council, but have a strong secondary interest in population studies.
In this long and persuasive memorandum, they also traced the origins of the council idea to the First National Conference on Cardiovascular Diseases, held in Washington in 1950, and its recommendation that "A continuing group should have the responsibility for reviewing the types of [epidemiological] studies under way and suggesting other areas for exploration."10 The memorandum outlined further how there had been, in effect, the continuous existence of a committee "under one name or another charged with the responsibility for the epidemiological aspects of the Heart Association's program." "The group has already shown initiative in achieving, unofficially, a loose sort of organization, and support for a series of small meetings about once a year. With the encouragement of Council status, they could become a useful part of the structure of the Heart Association."
At its meeting on February 26, 1961, it was moved "that the Executive Committee of the Council of Community Service and Education recommends creation of a new Council on Cardiovascular Epidemiology."9 However, on the next day, the first bend in the river was encountered in a motion by the Central Committee that the executive committee of each AHA council be polled for opinions on establishing a new AHA Council on Epidemiology, with results of the poll to be reported later to the Central Committee. (This seemingly benign recommendation for democratic procedure would, in fact, create obstacles from those within the existing scientific councils who have no interest in epidemiological studies. They would be able to retreat into the comfortable idea that AHA councils should not continue to expand indefinitely and thereby defer decisions until completion of the tedious formal study, ongoing at the national level, of the structure and function of AHA councils.)
From these partly encouraging and partly obstructive actions, the Committee on Epidemiological Studies at its May 5, 1961, meeting reaffirmed its position and proposed that a Council on Epidemiology be formed, in a motion that was carried unanimously. This motion was approved and forwarded by the Executive Committee of the Council on Community Service and Education to be considered 10 days later, at the May 15, 1961, meeting of the AHA Central Committee. The latter committee also reviewed the poll taken of AHA councils concerning creating a new Council on Epidemiology, a poll that was largely favorable.11 Nevertheless, AHA President Carleton Ernstene expressed opposition to separate status for epidemiology out of concern that it would "attract away" people working in the field of cardiovascular epidemiology, whereas other committee members were concerned about an increasing number of representatives on the AHA Research Committee and Board of Directors. AHA Medical Director Dr Wakerlin, in an attempt to resolve these concerns, asked the Central Committee to consider "whether a Committee on Epidemiology, while remaining small as a committee must, and reporting to the Central Committee, could not serve as an Executive Committee of a new Society of Cardiovascular Epidemiologists, keeping the committee small but permitting an associated larger group with an annual meeting separated from the AHA," a major goal of the protagonists for epidemiology. In response, Dr Paul pointed out that if any course were to be recommended at that meeting other than creation of a new Council on Cardiovascular Epidemiology, that proposal would have to be sent back through the entire system, since the request before the group was for council, not committee, status. The Central Committee then moved that the Committee on Epidemiological Studies be made a Council on Epidemiology and that its representation to the board and other bodies of the association be determined by an appropriate committee. This was carried by a vote of 9 to 3.11
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Shoals! |
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At the June 30, 1961, meeting of the Board of Directors, Chairman Dr Ernstene moved, on the basis of the Central Committee recommendation, that a Council on Cardiovascular Epidemiology be established. Then came the next tortuous bend in the river. It contained major shoals!
Board member and Council on Arteriosclerosis member Louis Katz proposed a substitute motion—that the recommendation for establishment of a Council on Epidemiology be referred back to the Central Committee to explore the possibility that the present Committee on Epidemiological Studies "mature by becoming a Committee of the Central Committee for Medical and Community Program, rather than blossoming out into a Council." Maintaining that "a matter of this importance should be settled by a full meeting of the Central Committee," he referred to representation problems created by setting up new councils and the desire of the board to contain the overall number of councils and committees. Dr Aaron Kellner, also a member of the Council on Arteriosclerosis, then joined in opposition, referring to the Central Committee's prior approval of a thorough review of the entire AHA Scientific Council structure. Dr Ernstene, board chairman, then returned to the point at hand: "that the recommendation for the establishment of a Council on Cardiovascular Epidemiology [had already been] thoroughly studied," reviewing all the particulars leading up to that recommendation. Dr Paul in turn emphasized that the epidemiological studies group "had been more active than some of AHA's existing Councils, and was now in an inept location in a community service and education slot inappropriate to its function." Nevertheless, with few dissenting votes, the motion of Dr Katz to table was carried. The entire matter of epidemiology was thus referred back to the Central Committee for further deliberation.12
On these shoals, the AHA council ship foundered for 3 long years.
(Years later, we learned from Jeremiah Stamler that Dr Katz' motives were more magnanimous than apparent at the outset. He had expressed privately to Dr Stamler his concern that creation of a new council on epidemiology would cause a flight of epidemiological "types" from the Council on Arteriosclerosis, which, he feared, might thereafter become mainly a "lipid club.")
At its November 6, 1961, meeting, the executive committee of the Council on Community Service and Education welcomed back into its fold the now somewhat-battered Committee on Epidemiological Studies. However, it recommended, encouragingly, that the committee "should itself give further consideration to the different possibilities and make appropriate recommendations after such further consideration." The Committee on Epidemiological Studies in turn agreed to await further activation about council status for the outcome of the national review of AHA council structure and expressed gratitude to the Council on Community Service and Education for continued liaison and support. The committee went on to request, however, that, as recommended by Central Committee, it become a Standing Committee on epidemiological studies of the Central Committee, under the assumption that this move would forward its ultimate organizational aims.13
In a 1962 meeting, the Central Committee emphasized "that their [the epidemiology group] request was not summarily turned down, but rather that every effort would be made to give epidemiology proper recognition and status."14 (Finally, part of the issue was recognized—equal status for epidemiology with the Basic Science Council and several clinical councils.) The epidemiological group was voted to become a committee of the Central Committee, "as an interim step to Council status," and this action was subsequently approved by the AHA Board of Directors.
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Interim Activities of the Epidemiologists: 1961 Through 1964 |
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Meetings of the Committee on Epidemiological Studies continued throughout this long period of AHA bureaucratic bandying, activities that proved crucial to eventual status as a formal scientific council. In particular, the annual scientific conferences on CVD epidemiology provided, in our view, the intellectual glue that held together the epidemiologists. These conferences were developed by the Committee on Epidemiological Studies, primarily during the tenures of Felix Moore and Oglesby Paul as chairpersons; Dr Paul provided critical leadership in organization and obtained private funding for the early conferences. The first conference in 1960 was crucial to "bonding" of the group. The conferences established an important tradition of presenting work in progress along with special reviews and lectures such as those by Ancel Keys on preventive trials and programs and that by Oglesby Paul celebrating the 10th anniversary of the council's founding.
Meanwhile, the Committee on Epidemiological Studies continued to meet and to plan. At its May 1961 meeting, which was chaired by Felix Moore, Fred Epstein reported on deliberations of the WHO in Geneva, which neatly paralleled the AHA focus on comparable methodology for epidemiological studies.15 These joint activities led not only to major steps in methodology but also to greater organization of CVD epidemiology. Also at this 1961 meeting, the committee acted to broaden its charge: "1) to provide advice and guidance to the Association concerning the approach to the problems of cardiovascular disease through epidemiological investigations; 2) to be concerned with improvement of procedures and methods used in conducting epidemiological studies and give consideration to problems of pooling results from various studies; 3) to keep the Association informed of current studies being made in the U.S. and abroad; 4) to make recommendations to the Association regarding interpretation of the results of epidemiological studies and of vital statistics data with respect to the scope and trends of cardiovascular-renal diseases; 5) to give advice and counsel on the practical applications of epidemiological studies to programs of community service and education; and 6) to cooperate with other Councils in the stimulation of programs of investigation, to `weave a thread' of epidemiology into the fabric of these investigative programs."15
In the July 1962 meeting of the committee, Fred Epstein reaffirmed the need for common criteria and methods in CVD epidemiology: "We must work toward a common goal, and in the course of moving ahead, establish common ground. It will require both science and art to define criteria and methods which are sufficiently simple to be universally applicable, and at the same time sufficiently broad to serve, as far as possible, the purposes of all epidemiological investigations and explorations." He then announced organization of a subcommittee on criteria and methods and appointment of its staff physician. It was also at this meeting that AHA staff took over ongoing responsibility for committee activities.16
In a February 1963 meeting, Oglesby Paul, now chairman of the Committee on Epidemiological Studies, announced that a scientific session on epidemiology was planned for the upcoming AHA Annual Scientific Sessions to be held jointly with the Council on Arteriosclerosis to provide a state-of-the-art summary of the knowledge about atherosclerosis gained through epidemiology along with its pathological, laboratory, and physiological aspects. This first major session on CVD epidemiology at the AHA Annual Scientific Sessions became another milestone in the history of the council.17
At the January 31, 1964, meeting of the Committee on Epidemiological Studies, there was active discussion of the downward trend in cerebrovascular death rates in men, with much puzzlement among the epidemiologists and AHA officers. The concern was in particular that the stroke mortality trends might be due to coding artifact. No conclusions were reached, however, about the reality, or the meaning, of the trends (and no subcommittee was established to examine them).
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The Year of the Big Push: 1964 |
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At a crucial February 29, 1964, meeting of the AHA Central Committee, Oglesby Paul again reviewed the history of the formation of the Committee on Epidemiological Studies and its quest for council status since 1961.18 He cited all prior recommendations, including recent ones of the Ad Hoc Committee of Council Chairmen and of the Long-Range Planning Committee of the AHA, both of which had recommended council status for epidemiology. In conclusion, he proposed that it would be desirable to move forward promptly because the AHA would likely require another year or longer to develop a comprehensive plan for its Scientific Councils.
At this meeting, the inertia was at long last overcome. A motion was passed "that the Central Committee for Medical and Community Program of the American Heart Association approve the recommendation of the Committee on Epidemiological Studies that it become a Council of the AHA and at the June 5th and 6th meeting of the Board of Directors that those changes be made in the AHA by-laws to accommodate the new Council."18
At the September 26, 1964, meeting of the Executive Committee of the AHA Board of Directors, it was duly voted "to adopt the rules and regulations of the Council on Epidemiology as modified."19
This final action formally created the new AHA Council on Epidemiology.
The official AHA announcement of the new Council on Epidemiology came in the Council Letter Summer 1964 issue: "The Committee on Epidemiological Studies, first a Committee of the Council on Community Service and Education, and then a Committee of the Central Committee, will now become a Council of the American Heart Association. It is hoped that as a Council, this group will attract additional epidemiologists to the American Heart Association. Dr Oglesby Paul of Chicago is the chairman of the new Council."
The name of the new council appeared on the masthead in the next issue of the Council Letter (in October 1964), but somehow disappeared from the Summer 1965 issue and then reappeared in the Winter 1965 issue. In Summer 1965, the Council Letter announced formation of the Department of Councils and International Program with staff to support all eight AHA Scientific Councils. At that time, Leonard Cook, AHA statistician, received a "permanent appointment" to staff the Council on Epidemiology.
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Trying Its Wings |
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At the October 23, 1964, AHA Annual Scientific Sessions in Atlantic City, NJ, the epidemiological group first met as a formal council, approved its rules and regulations, and set dues at $5 for fellows and $2 for members. The recently published report in Circulation on criteria and methods and an accompanying editorial were acknowledged.20 21 The AHA Pooling Project was under way with a funding proposal off to the NHI. The CVD Newsletter was well established. The first budget request was submitted (for $9215) to support two meetings of a 15-person executive committee and two meetings of a 12-person criteria subcommittee as well as working groups, data collection and processing, an annual conference, and the newsletter. An invitation went out promptly to a distinguished group of leaders in cardiovascular medicine to "grandfather" them into the new council.
Thus, the new council's activities went on in a seamless fashion from past meetings of the Committee on Epidemiological Studies. The council had gotten off to a strong start.
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The First Decade: 1965 Through 1974 |
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Science
The new AHA Council on Epidemiology continued to have a strong focus on methodology in its deliberations and committee work. In addition, at its annual scientific conferences, increasing numbers of preliminary reports were made on research results from surveys, cohort studies, and clinical trials in progress. We have briefly categorized them.
Prediction and prognostic power of CVD risk factors and of clinical and ECG findings were a major interest, and behavioral traits entered strongly into research and discussions.
Sophisticated analytical methods came to the forefront during this period; for example, results of the Truett-Cornfield-Kannel multivariate logistic model, applied to the 12-year Framingham Heart Study follow-up experience, were presented at the 1967 annual conference.
The 5-year results from the Seven Countries Study cohorts gave the first indications of strong ecological correlations among diet, serum cholesterol, and coronary disease in populations with differing diets. The first report was given from the 8-year follow-up on type A behavior and CHD risk of the Western Collaborative Study Group. Major reports emanated from the established cohort studies; the Framingham, Albany, Evans County, Chicago, and Tecumseh studies, as well as from the Minnesota CVD Study and from other cultures, including the Pima Indians, Honolulu Japanese, and Solomon Islanders studies.
Early reports abounded from the clinical trials that so strongly influenced later CVD research, including the VA trials of antihypertensive drugs in moderate and severe hypertension. At the end of the period, in 1974, announcements and preliminary reports were given from major clinical and preventive trials sponsored by the NHI, including the Coronary Drug Project and the Hypertension Detection and Follow-up Program.
The council, and the numerous studies of its investigator members, had hit full stride.
Organization
Minutes of the annual business meetings reveal
that by 1965, the
new council had 261 members, of which 220 were fellows. Its CVD
newsletter was renamed the CVD Epidemiology Newsletter, and
annual publication of an international issue began, with Fred Epstein
as editor; this was one of the few direct international links of the
AHA. The council's Committee on Criteria and Methods was involved in a
national survey of CVD population studies and in a proposal to the NHI
to conduct the AHA Pooling Project, the first statistical summary of
risk factors and individual CHD risk from US cohort studies.
Early in this first decade of the new council's formal existence, the Diet-Heart Study, a double-blind feasibility trial of diet and lipid lowering, was carried out at five national medical centers and was successfully completed; its results were published in Circulation in 1968.22 The report was followed by a hiatus in action due to a major quandary at the NHI on the appropriate research course to take. The Executive Committee of the council, in its minutes, letters, and public statements, expressed concern about "the lack of activity of the National Heart Institute to get the definitive Diet-Heart Study underway, and the repeated evaluations by various ad hoc committees of the feasibility trial." The council recommended that "studies should be initiated as soon as possible, in successive stages if necessary, but the decision should be made and made soon."23 The council thus vigorously encouraged the institute to arrive at a decision. Eventually, the analysis of the Ahrens Committee of the NHI concluded that a definitive controlled trial was not feasible, in effect setting aside a definitive diet-heart study "for all time."24
In fall 1968, the new council, along with the NHI, the International Society of Cardiology (ISC), and the WHO, jointly sponsored the International Conference on Mass Field Trials for the Prevention of Coronary Heart Disease, in Makarska, Dalmatia, Yugoslavia, during the Seven Countries Study survey. The report of this landmark conference had a powerful influence on subsequent NHI policy, culminating in a generation of CVD preventive trials during the 1970s and 1980s.25
During this period, strong links were forged between the new council and the ISC, particularly its research committee. The experience and forceful representations of AHA council members played a determining role in New Delhi, India, at the 1966 World Congress of Cardiology in reorganization of the ISC along the lines of AHA Scientific Councils. Moreover, the first ISC International Seminar on CVD Epidemiology, held during the Makarska Conference, proved to be a successful, long-term undertaking of the ISC in professional education and was led for a number of years by Richard Remington, Geoffrey Rose, and Jeremiah and Rose Stamler. It provided the model for the 10-day US seminar in CVD epidemiology that was established in 1975 with Darwin Labarthe as director to meet the burgeoning need for training of young US investigators in epidemiological skills. These seminars were to play an important role in the progress of CVD epidemiology in North America and around the world.
It was during this time that the Council on Epidemiology joined with other AHA scientific councils in reaction to a powerful central administrative move to regionalization of the AHA. The councils voiced a common concern that scientific councils' representation was lacking at the level of the Board of Directors and that council voices were insufficiently heeded in AHA affairs.
After almost a decade of work, the council's first major research effort, the AHA Pooling Project Report, appeared in 1978 as an AHA Monograph and as a supplement to the Journal of Chronic Diseases.26 Those publications had a major strengthening effect on the risk factor concept as the basis for preventive action. They established irrevocably the quantitative relations between serum cholesterol, blood pressure, and smoking levels and CHD risk. Moreover, the findings were valid across different studies, permitting extrapolation of data on relative risk to populations with varying absolute risks of CHD.
Toward the end of this time period, the AHA disseminated among practitioners 100 000 copies of the AHA Handbook on Coronary Risk. The council executive strongly commended Theodore Cooper, National Institutes of Health director, for implementing the national program against CVD with a whole generation of National Heart and Lung Institute–sponsored preventive trials and demonstration projects, acknowledging "the debt of the epidemiological and prevention community for his leadership."27
The decade closed with the council expressing its condolences to Mrs White on her, and its, great loss with the death of Paul Dudley White.
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The Second Decade: 1975 Through 1984 |
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This decade began with the success of the primary teaching activity of the council, the 10-day US seminar on CVD/Epidemiology, along with formation of its stable faculty, strong curriculum, and popular site at Granlibakken Resort, Tahoe City, Calif. This activity, still ongoing after 20 years, has for many years been jointly supported by the AHA and NHLBI.
During this period, a major battle developed between the National Commission on Egg Nutrition (NCEN), several council members, and the AHA. In response to a Federal Trade Commission (FTC) order claiming misleading advertisements by the NCEN about "eggs and cholesterol," NCEN lawyers subpoenaed the personal records and correspondence of the AHA and council members in a "fishing expedition" for evidence of political control and financial support hostile to the cause of the egg industry. They found none. Two years of litigation resulted in an FTC decree for the NCEN to "cease and desist" in its misleading newspaper advertisements about eggs in nutrition, in penalties levied against it and its advertising agency, and in a temporary period of quiet from that industry. The AHA thereafter highlighted for its council members the potential conflict of interest, or the perception thereof, for investigators who identified themselves with any special commercial interest in nutrition.
Science
The intellectual preoccupations of the council,
manifest in its
annual scientific conference programs and CVD Epidemiology
Newsletter, became more sophisticated in the second decade of its
formal organization.
Reports were made on hemostatic factors in coronary disease and on the importance of lipids and lipoprotein subfractions in CHD risk prediction. There were early reports from major preventive trials, Coronary Drug Project, Acute Myocardial Infarction Study, Beta-Blocker Heart Attack Trial, Treatment of Mild Hypertension Study, Lipid Research Centers Coronary Primary Prevention Trial, and Multiple Risk Factor Intervention Trial. First reports were given of "obligate" blood cholesterol lowering in the ileal bypass trial POSCH.
Observational studies remained active despite the emphasis on preventive trials during this period, with reports of trends in risk factors and of ethnic differences in risk and CVD rates in Hispanics in San Antonio, Tex, and in blacks in the Charleston Heart Study, Evans County Study, Hypertension Detection and Follow-up Program, and National Health and Nutrition Examination (NHANES I). The distribution and "tracking" of children's risk factors into adolescence were reported from the Muscatine and Bogalusa studies.
Warnings were sounded about possible unfavorable effects of diuretics on risk factors and on mortality in certain subgroups. Initial findings were reported on insulin and CHD risk and on alcohol consumption and CHD risk. The first report was made on apparent inverse relations of blood cholesterol level to individual risk of non-CVD. Beneficial effects of stopping smoking were reported among patients with CHD.
Recognition of the major downward trend in CHD mortality rates in the United States, starting in the mid-1960s, came belatedly in the mid-1970s when council members and committees became involved in rigorous studies to detect, measure, and explain CVD risk factor and mortality trends.
At the end of the decade, preliminary reports were made of the nature and dissemination of health promotion programs from the three large community CVD-prevention demonstration projects sponsored by the NHLBI, the Stanford, Minnesota, and Pawtucket studies.
Organization
In line with council recommendations during this
period, the AHA
Board of Directors developed policy "that prohibited smoking and
serving foods not consistent with AHA's diet recommendations at
official AHA functions." The council was involved in an ongoing
struggle for sessions and symposia on epidemiological contributions at
the annual AHA meeting as well as for council representation on
the national Program Committee. It used the powerful arguments of
program balance and equity between disciplines. The council, through
The Remington Report, made amazing, if appropriate, proposals such as:
"at least $1 billion should be added to the federal health research
budget—these dollars should be taken from other major federal budgets,
for example, defense, agriculture, energy or
transportation."28
Throughout the decade, the Council on Epidemiology reacted to the process tending to reduce the role of the Scientific Councils in the affairs of the AHA, pointing out to central administration that "the AHA has little substance or inspiration in the absence of the input of its Scientific Councils and expert volunteers." The council claimed further that the administrative reorganization of AHA "put program and policy on the back burner" and tended to give administrators more influence than investigators or physicians in determining major new directions of AHA activities.29 In fact, the various reorganizations of AHA were intended for just this purpose, based on strong views by many AHA administrators and affiliates that the Scientific Councils had much power and sometimes used it to obstruct community programs.
The council maintained pressure on AHA central administration to occupy itself with threats to "balanced" NIH funding of investigations across the broad spectrum of research strategies. It regarded with anxiety and argued forcefully against the increasing policy of AHA to use its name and logo in endorsement of commercial products and programs labeled "healthy." (This AHA policy was eventually overturned, in part due to protests from individuals and councils, but primarily due to disputes between AHA and industry concerning the price of AHA endorsement. There also was a real conflict with Food and Drug Administration policy about health claims for products. All of these issues took several years to work through.)
At the end of the second decade of its organization, in 1984, the council welcomed the new director of NHLBI, Dr Claude Lenfant, and his establishment of the Division of Epidemiology and Clinical Applications (DECA). This move was perceived by the council "as a timely challenge for the discipline, increasing its visibility."30
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The Third Decade: 1985 Through 1994 |
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Science
The broadened intellectual interests of the Council on Epidemiology in its third decade were represented in its annual conference programs and newsletter (as abstracted). A more extensive review of recent scientific advances from researches in epidemiology and prevention is available in a 1994 NHLBI Task Force Report discussed below.
Major attention was given in this period to downward trends in population death rates from CVD observed in the vital statistics of the National Center for Health Statistics and in entire communities as represented in the Corpus Christi Heart Project and the Minnesota Heart Study. Important trends were also observed in levels of blood pressure and hypertension prevalence, blood lipids, and smoking habits in the same studies and among young adults in, for example, Coronary Artery Risk Development in Young Adults (CARDIA). Major reports were made on CVD risk factors in the elderly and among ethnic groups from the Cardiovascular Health Study, Honolulu Heart Study, and Strong Heart Study.
Findings about the long-term prediction of disease and death with CVD risk factors and their changes over time were presented in 20- to 30-year follow-up data from the Framingham Heart Study; The Seven Countries Study; Chicago People's Gas Company, Western Electric Company, and Chicago Heart Association studies; Charleston Heart Study, and Evans County Study.
The largest body of cohort data on risk factors ever systematically analyzed was reported from the 11-year follow-up of 361 000 middle-aged men, the screened population of the Multiple Risk Factor Intervention Trial (MRFIT). It established definitively, among other things, the smoothly curvilinear relation of entry serum cholesterol level to subsequent risk of CHD death.
Many years after the report of the AHA Pooling Project, systematic meta-analyses of data from longitudinal studies became a preoccupation of some researchers (and a concern to others) in efforts to find risk factor effects that individual studies had inadequate power to detect.
Much of the interest in type A behavior shifted to attempts to dissect component effects of hostility and anger and to the risk associated with restricted social "networks" and with "hopelessness." The importance of central obesity was recognized as an independent predictor of cardiovascular risk.
Thus, observational studies flourished in this period on CVD risk factors measured across cultures and among women, minorities, ethnic groups, the "socially disadvantaged," the young, and the elderly.
Definitive effects in reducing CVD risk by treating systolic hypertension were reported from the Systolic Hypertension in the Elderly Program (SHEP). There was greater research focus on decreasing stroke mortality rates and its principal components: reduced incidence and early mortality. The importance was recognized of left ventricular mass in prediction of outcome among hypertensives. A series of trials was reported on the primary prevention of hypertension by intervention on obesity, ratio of intake of sodium to intake of potassium, and alcohol intake. These, along with newly designed observational studies on diet and blood pressure, including INTERSALT, set the stage for major NHLBI reports and broad initiatives in high-risk and in population strategies for the primary prevention of hypertension.
A delayed favorable treatment effect was observed on mortality rates among MRFIT Special Care participants years after the formal multiple risk factor intervention was completed. Results long after the conclusion of the Coronary Drug Project showed an apparent continued favorable effect of the earlier treatment of hyperlipidemia with nicotinic acid in post–myocardial infarction patients.
Attempts were made to analyze the ecological relations among trends in behaviors, risk factors, and deaths from CVD, non-CVD, and cancer, with evidence developed for there being common risk factors. Council reviews concluded, therefore, that primary prevention strategies should lower death rates for both CVD and several non-CVD causes but would, for a time, increase prevalence of CVD in the aging population.
Much attention was given to the relations among obesity, body fat distribution, glucose tolerance, insulin resistance, and blood pressure. Interest developed in DNA polymorphisms and their distributions in the population. Atherosclerosis Research in Communities (ARIC), the successor to the Framingham Heart Study, began a multicenter, multicultural approach to the study of "new" CVD risk factors and reported on many such factors, including lipoprotein(a), factor VII, and fibrinogen levels; serum ferritin; passive smoking; postmeal fat tolerance; plasma homocysteine; and health care use.
The first major "postal" cohort studies were reported from Harvard University and the University of Minnesota, and "mail order" randomized trials, chiefly from the Harvard group, reported preventive effects of low-dose aspirin on recurrence of myocardial infarction.
Great excitement surrounded the development of new ultrasonic, noninvasive methods for the measurement of atherosclerosis. A flurry of lipid-lowering trials ensued—pharmacological, surgical, and hygienic—showing a potential for prevention of progression or actual regression of atheromas.
The role of diet was elaborated, with particular interest in antioxidants, fish, fiber, fresh fruits and vegetables, and boiled coffee, along with continued interest in the fatty acid and cholesterol composition of the diet as related to thrombogenesis and atherosclerosis and in the effects of diet on CVD risk independent of blood lipid effects.
NHLBI-supported community prevention programs, the Stanford, Minnesota, and Pawtucket programs reported actively on the impact of their programs on population-wide health behavior. Later in the decade, these programs reported consistent findings of rapid downward trends in average cardiovascular risk factor levels in their communities. They also reported difficulty in detecting changes in risk or disease rates that could be ascribed with confidence to community-wide interventions. The difficulties apparently occur in getting programs disseminated among sufficient people in the community, in distinguishing program effects from rapid background changes ongoing in society, and in dealing with unexpectedly large variability over time of population risk factor levels.
Organization
The council coordinated all program plans for
the Second
International Congress on Preventive Cardiology (held in 1989 in
Washington, DC), the success of which, among other undertakings,
allowed the council to establish a New Investigator Award in the name
of Jeremiah Stamler and a Lecture on Methodology in the name of Richard
Remington. It actively consulted in the program for the third Congress
held in Oslo in 1993 and is directly involved with planning for the
Montreal Conference in 1997. Early in its third decade, the council
moved to change its name to the AHA Council on Epidemiology and
Prevention, with the idea that this change would foster prevention
activities across CVD fields and among AHA Scientific Councils. The
council was newly accredited by the Steering Committee of AHA, having
grown by 1990 to 750 members.
The first named lecture in CVD epidemiology, the Ancel Keys Lecture, was sponsored by the council and given at the AHA Annual Scientific Sessions in Dallas in 1990 by Geoffrey Rose.31 In the lecture, he elaborated a classic concept of "sick populations and sick individuals," updated to show the change in proportion of high-risk persons created by small shifts achievable in the population distribution of risk factors. The second Ancel Keys Lecture, given by Henry Blackburn in 1991 at Anaheim, Calif, summarized the contributions of CVD epidemiology to knowledge about the population causes and prevention of CVD and its influence on the public health. It also sounded an alarm over the discriminatory effects on epidemiological research of the decrease in available NIH research funds and of the "corrective" strategies applied by the NHLBI administration to this decline in real funding.32
Tension grew during this decade, both within the AHA and throughout the scientific community, as a result of reduced real monies for NHLBI and the effects of NHLBI corrective responses to these economic stresses. These administrative responses, along with funding caps and increased NHLBI controls over research, tended to affect epidemiological grant proposals selectively because of their inherent duration, size, and cost. Simultaneously, priority scores for the funding payline at NHLBI descended from the 30th percentile of approved applications in the mid-1980s to the 12th percentile in the mid-1990s, even as the absolute NHLBI budget rose steadily to $1.5 billion. Concerns of the council grew over the devastating impact on the scientific community, particularly on young investigators, of the lack of stable research support.
The distress among all CVD investigators reached a critical point nationally at the November 1991 AHA Annual Scientific Sessions in Anaheim, Calif, where "the natives grew restless," publicly venting their concerns to the director of NHLBI. The particular approach taken by the Council on Epidemiology and Prevention was also forceful, but it attempted to be deliberative and constructive in its criticism and proposals. This led to the prompt appointment by Claude Lenfant of an NHLBI Task Force on Research in CVD Epidemiology and Prevention, whose report was released in September 1994.33
The present status and future needs for new knowledge and research in CVD epidemiology and prevention are well reflected in the priority recommendations of that task force, as summarized. These priorities also represent well the major current intellectual preoccupations of members of the AHA Council on Epidemiology and Prevention.
Prevention of adverse lifestyles and related risk
factors
(This goal of prevention of initial elevated risk, called "primordial prevention" by the WHO, is recognized as the prime challenge to CVD epidemiology and prevention research and public policy.)
Control of high blood pressure and other established
CVD risk factors
(This was considered the necessary medical preventive strategy to complement a public health, population strategy.)
Reduction of
CVD events, disability, and death
associated with socioeconomic differences
(Reducing the risk among groups at a socioeconomic disadvantage is regarded as essential to the larger goal of effective CVD prevention.)
Prevention of hypertension, dyslipidemia, smoking,
and atherosclerosis beginning in youth
Improvement of
population-wide prevention
strategies
Clarification of the association among insulin,
glucose, and atherosclerosis
Development of technical resources
and improved
measurement techniques
Expansion of research training programs
in
disciplines relevant to CVD prevention and epidemiology
In 1992, the Ancel Keys Lecture, given at the Annual Scientific Sessions of AHA in New Orleans, La, by Jeremiah Stamler, dwelt on the important historic and ongoing role of nutrition in CVD and its measurement. The Keys lecture in 1993 by Frederick Epstein, given in Atlanta, Ga, provided an overview of the developments in CVD epidemiology and prevention research and their powerful implications for public health, including reduction of noncardiovascular as well as cardiovascular death rates.
The third decade of the council's formal activity closes in 1994 with its membership at 1100, of whom approximately one third are fellows, and with a smoothly functioning committee structure. The council now has strong leadership from a new generation of well-trained, committed, and politically concerned CVD epidemiologists who are no longer linked directly to the 1950 origins of the council or of CVD epidemiology itself. Such a transition to new leadership is believed to be a sign of "institutional health." This history was written in part for that new generation.
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Conclusions |
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Our review suggests that the AHA Council on Epidemiology and Prevention is unique in several ways beyond its troubled origins, including in its influence as a professional society by the rigorous communications in its annual scientific conferences; in its directed research efforts such as the AHA Pooling Project and reports on methods and future research needs; in fostering CVD research and training and their support; in its joint efforts and rich interactions with the AHA nationally and with the NHLBI, the WHO, the International Society and Federation of Cardiology, the Society of Preventive Cardiology, and the American College of Cardiology; and in its effective advocacy of preventive cardiology and the public health.
The Council on Epidemiology and Prevention has achieved, by good works and perseverance, much of the influence and opportunity it long sought in CVD research, in the AHA itself, and in public affairs. It faces the next century as a vigorous organization forwarding epidemiological researches, preventive programs, and professional training. It provides an effective force for sound public policy in the prevention of CVD and the promotion of health.
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Acknowledgments |
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We are particularly indebted to Len Cook, long-term AHA staff member who is now retired, and to current staff member Susan Lucius, who came up with critical documents of council meeting minutes, conference programs, letters, and memoranda from the AHA National Center Archives, and to Len Cook for his own early history of the council written in 1965. We are also grateful for suggestions and materials from Oglesby Paul, first chairman of the council, and from Jeremiah and Rose Stamler. Bruce Fye's trailblazing history of the Council on Clinical Cardiology (Circulation. 1993;87) was a great encouragement.
We are especially grateful to Richard Remington and the leaders of the Council on Epidemiology and Prevention in 1978, who charged us with this pleasant task, and to recent Chairpersons Russell Luepker and Steven Fortmann, who have encouraged and strongly supported this undertaking.
Received September 28, 1994; revision received December 7, 1994; accepted December 11, 1994.
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References |
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