IJE Advance Access originally published online on October 31, 2005
International Journal of Epidemiology 2005 34(6):1187-1188; doi:10.1093/ije/dyi177
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Commentary |
Commentary: Medical aspects of the Framingham Community Health and Tuberculosis Demonstration
Department of Neurology, Boston University, Boston, MA 02215, USA
Corresponding author. E-mail: wkannel{at}bu.edu
The Framingham Community Health and Tuberculosis Demonstration Study1 not only showed that community control of disease-producing factors is feasible and effective for combating tuberculosis but also that this approach was likely to be the foundation for the investigation of the causes and control of other chronic diseases that impact the population. The US Public Health Service, recognizing a growing epidemic of coronary heart disease (CHD), funded the Framingham Heart Study to explore the causes of heart disease in 1948. It was not clear how best to go about doing this. Like the population Tuberculosis Study initiated in 1916, it was initially decided to do a community disease control demonstration programme, but later, under the auspices of the newly established National Heart Institute, it was directed at seeking out correctable predisposing causes and clues to its pathogenesis.2 This change in the Framingham Heart Study objectives was initiated by Felix Moore at the National Heart Institute and by Thomas Royal Dawber, the chief architect of the Framingham Heart Study, owing to the lack of information about causation and no handle on practical means of prevention. CHD was thought at that time to be an inevitable consequence of age and genetic makeup. The Framingham site for the study was promoted by Professor David Rutstein, newly appointed to chair a department of preventive medicine at the Harvard Medical College. Equally persuasive was Paul Dudley White, a leading cardiologist of the day, who had just been named executive director of the National Advisory Heart Council and chief medical advisor to the National Heart Institute.
The town of Framingham was selected because its residents had already shown their willingness to cooperate with medical researchers. From 1916 to 1923, 5000 Framingham residents had volunteered to participate in the long-term Framingham Tuberculosis Demonstration Study. In a preventive effort, residents were examined for tuberculosis and by the end of the study the community physicians were finding and treating the disease sooner. In 1925, 2 years after the completion of the study, 75% of cases were found in an early stage compared with 45% in 1916. Early treatment and improved sanitation led to a 55% decrease in tuberculosis cases and a 6% decline in the death rate. After 1923, Framingham town officials continued the work and the Framingham model became incorporated in county and city tuberculosis programmes nationwide.
The tuberculosis study set the stage for the use of Framingham, Massachusetts as a ‘social laboratory’. The assertion by Anderson that ‘knowledge of the progress of the work (Tuberculosis Study) may stimulate studies elsewhere’ has certainly come about, both at Framingham and worldwide. The Framingham Heart Study took many of the same steps in organizing a community recruiting effort, soliciting the cooperation of the local physicians and the health department, and diagnosing the disease outcome. The Study also used medical consultative services to establish the presence of disease and select hypotheses to test. The major difference was that the Framingham Heart Study did not intervene, concentrating instead on seeking out the predisposing factors and the incidence and clinical characteristics of the disease as it occurs naturally in the population.
Thus the landmark Tuberculosis Demonstration Study not only sparked an era of public health community control of an infectious disease3 but also an epidemiological population-based approach to seeking out the predisposing factors leading to the occurrence of many chronic diseases of unknown origin. The Tuberculosis Study of 1916 should be listed among the milestones in the historical development of chronic disease control in the US along with cancer reporting in New York State in 1911, the first population-based cancer-reporting registry in Connecticut in 1935, and the Framingham Heart Study in 1948.4
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1 Armstrong DM. The medical aspects of the Framingham community health and tuberculosis program journal. Am Rev Tuberc 1918;2:195–206. (Reprinted Int J Epidemiol 2005;34:1183–87.)
2 Dawber TR, Meadors GF, Moore FEJ. Epidemiological approaches to heart disease: the Framingham Study. Am J Public Health 1951;41:279–286.
3 Edwards HR. New Haven Department of Health Monthly Bulletin March 1928 Vol. LV No. 3 (excerpt of pg 6).
4 Brownson RC, Bright FS. Chronic disease control in public health practice: looking back and moving forward. Public Health Rep 2004;119:230–238.[CrossRef][ISI][Medline]
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