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The Evolution of Public Health Research: Heart Disease, Part 1

Posted by Amy Brankin on Oct 6, 2016 10:00:56 AM

How a Radio Game Show and a Town in Massachusetts Invented Biobanking and Redefined Public Health Research

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The answer was “Jack Benny.”  The question, posed as a contest held by the popular radio game show Truth or Consequences was, “Who is the Walking Man?” 

The contest, held in 1948, was designed to generate contributions to charity. The popular game show held many such contests, leaking clues over time and encouraging listeners to send in their guesses and contributions. The chosen recipient of the funds raised by this particular contest was a tiny scientific society of cardiologists called the American Heart Association. By the time the “Walking Man” was identified as Jack Benny, the show had raised $1,575,000 and unknowingly pivoted public health in a bold new direction.

Public health and epidemiology began as the study of epidemics, or “that which is thrust upon us.” With the rise of smoking-related lung cancer and cardiovascular disease in the 1950s, epidemiology has also become a study of “that which we do to ourselves,” a massive cultural shift. Public health officials and researchers shifted focus from tracking epidemics and data collection (to inform public policy), to investigating root causes and also influencing the behavior of individuals. This shift in focus, and the enormous impact of public education about the cause of disease, was led by the suddenly well-funded American Heart Association (AHA).american_heart_association_logo.jpg

At about the same time the AHA received the game show windfall, another project was organized between the Massachusetts State Department of Health, the Harvard Medical School Department of Preventive Medicine, and the US Public Health Service. One aspect of the project was a demonstration program for developing “case finding procedures” for heart disease: volunteers would be recruited for physical exams over an extended period of time. To run such a program, they needed a community with a large enough population of men aged 30 to 59, a stable economy (for a stable population base), a well-organized health department, a medical center, and a supportive community of medical professionals. They found it in Framingham, Massachusetts.

Now, we need to backtrack a few decades.  The AHA had been organized by six cardiologists in 1924. At the time, the cause of heart disease was a mystery, and there was little the medical profession could do for those few who survived a heart attack. The AHA began recruiting other scientists and physicians in efforts to address the illness, but through the 1930s and ‘40s, the news surrounding cardiovascular disease continued to worsen. While infectious disease declined dramatically (thanks to improvements in sanitation and the advent of penicillin) an unexpected new tidal wave of heart disease, accompanied by lung cancer, swept into medical practices and hospitals. By 1950, one of every three men over the age of 60 had cardiovascular disease!

cardiovascular_disease.jpgMany considered a cure to be unrealistic—death from a degenerative, if not an infectious, disease was considered the norm at the time.  And unlike infectious disease, the multiple factors that caused heart disease, cancer, and other disorders could not be identified in a laboratory.

However, change began in 1948 on two independent fronts, as the AHA made critical and innovative decisions regarding the game show funds, and the Framingham study began taking shape.  

The Framingham Study was intended as a search for the prevention, or at least a delay of onset, if not reversal, of the scourge of heart disease.  However, the “case finding” team soon realized that their project had tremendous potential to answer bigger questions, and they wasted no time in implementing numerous innovations. For instance, at the time, nearly all epidemiological research was short-term and focused on a single variable. The case finding team assumed that cardiovascular disease did not have a single cause, and they planned to run the program for many years. Many other elements soon became clear:

  • The volunteer population was much healthier than the population as whole, and a so a strategic sampling plan was needed.
  • The initial target number of participants was not large enough for statistically meaningful analysis.
  • The questionnaire needed to collect far more data, and the study also needed to collect blood samples, leading to another innovation―the research biobank.

Within a year, administration of the now-named Framingham Study was transferred to the newly created National Heart, Lung and Blood Institute (NHLBI) at the National Institutes of Health, and before the mid 1950s, the Framingham Study had begun pinpointing the role of dietary fat, cholesterol levels, and smoking in heart disease.

In the meantime, the AHA was transforming itself from a small scientific society to a nationwide entity focused on improving health, both through research and through public education. The AHA awarded its first research grant within a year, in 1949, and by the middle of the 1950s, was funding additional studies and was also actively working to educate the public about the connections between dietary fat, cholesterol, and heart disease, as well as the dangers of high blood pressure. As the links between heart disease and life habits, such as diet (cholesterol levels) and smoking were revealed― mostly by the Framingham study―the AHA took the information out of the scientific domain and promoted health choices in the US population.

The dramatic reduction in cardiovascular disease that occurred between 1960 and today should be the happy ending, but unfortunately, we are not at the end of our story.  To learn more you’ll have to stay tuned for Part 2 of this blog post.

In the meantime, we recently published an eBook on Controlling Preanalytical Variability in Biospecimen Collections. This is an issue that must be thoroughly addressed in public health research – the possibility that the handling of specimens prior to lab testing has skewed results.  To read more, download our eBook below.

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