IJE Advance Access originally published online on October 31, 2005
International Journal of Epidemiology 2005 34(6):1188-1190; doi:10.1093/ije/dyi178
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Commentary |
Commentary: The first Framingham Study—a pioneer in community-based participatory research
Center for Public Health Research and Prevention, PO Box 2067, Hagerstown, MD 21740, USA. E-mail: gcomstoc{at}jhsph.edu
The first Framingham Study of cardiovascular diseases was initiated in 1947 in the Massachusetts town of that name. After various experts spent 3 years considering various study designs, the final basic design was adopted.1 In this form, it is known to all cardiologists, most epidemiologists, many physicians, and even some laypersons.2 In contrast, almost no one now alive has heard of the Framingham Community Health and Tuberculosis Demonstration, which started 33 years earlier in 19173 even though its success contributed to the selection of Framingham for the cardiovascular study.4 The first study dealt with tuberculosis because at that time it was still a leading contender for the title given to it by John Bunyan, ‘The Captain of all These Men of Death’.5 In the Death Registration Area of the United States in the Census year of 1910, tuberculosis had just recently fallen to second place among the causes of death, only slightly behind the group of diseases classified under the rubric ‘Diseases of the Heart’.6
At that time, 18% of the amount paid for death claims in the Industrial Department of the Metropolitan Life Insurance Company was for tuberculosis.3 To reduce the burden of tuberculosis among its current and prospective policy holders, the Company started a series of educational campaigns aimed at the general public and policy holders. Case-finding and medical programmes were established for its employees, including the construction of a company-owned and operated hospital, Mount McGregor Sanatorium.
The crown jewel of the Metropolitan's health projects was the Framingham Community Health and Tuberculosis Demonstration. The basic plan was set forth by Dr Lee K Frankel, head of the Company's Welfare Division. In a letter to the National Association for the Study and Prevention of Tuberculosis, the forerunner of the American Lung Association, he offered the Association $100 000 to conduct a 3 year study in which the ‘most advanced techniques available’ would be applied to a community of 15 000–16 000 persons, preferably in New York or Massachusetts, with the goal of reducing the tuberculosis burden as much as possible. The results would be evaluated by comparing subsequent tuberculosis death rates with those in seven similar control communities.3
After some months of study, Framingham, Massachusetts was selected as the site of the Demonstration. It was a town with mixed industries whose workers came from a variety of European countries. The tuberculosis death rate was similar to that of the United States as a whole. Both the local and state health departments were rated good to excellent.
An important consideration was the offer of many local organizations in Framingham to help in carrying out the project, thereby making it clear that the Demonstration would be a true community effort rather than an experiment on the town conducted by outsiders. Prominent citizens sat on the supervisory committee along with nationally recognized tuberculosis experts.3,7 Throughout the duration of the Demonstration, every effort was made to emphasize that this was a community enterprise, even to including the word ‘Community’ in its formal title, the Framingham Community Health and Tuberculosis Demonstration. Adding to the sense of community, the Executive Director of the Demonstration, Dr DB Armstrong, apparently lived in the town.
During the first year of operation, all aspects of the Demonstration went so well that the Metropolitan Life Insurance Company granted an extension of another 4 years to continue and complete the studies. The following account of the Demonstration's activities and their results applies to the entire 7 years of support.
The Demonstration had numerous facets, all focused on promoting the health of Framingham. The main activity was to conduct careful physical examinations on all residents of the town with special emphasis given to tuberculosis. Local physicians were given special training for these examinations. Fluoroscopy was almost routine and chest radiographs were made when indicated. Both were rarely available in small towns at that time. Their pioneering use in Framingham speeded their addition to the diagnostic armamentarium for chest diseases. Although Koch had introduced microscopic examination of stained sputum smears in 1882,5 their use was not mentioned and was probably not done. To improve uniformity of diagnoses, lectures were given at the newly formed medical club, and a set of diagnostic standards was developed and printed, an example soon followed by the National Association. During the first year, the number of reported cases rose from 27 to 180, with the proportion of early cases increasing from 45 to 83%.8,9 This extensive case-finding and treatment programme had a significant effect on case rates. In Framingham, they dropped from 121 per 100 000 per year during the decade 1907–16 to 38 per 100 000 in 1923, a decrease of 68% compared with only 32% in the control towns. Framingham's advantage persisted for at least several decades.3
One of Framingham's ‘yardsticks’ was the ratio of annual tuberculosis deaths to the number of active cases living in the community. Everyone knew that deaths represented only the tip of the iceberg, but how much was submerged and undefined? The Framingham experience showed that the ratio was close to nine living cases for every annual death.3 Of all the Framingham results, this ratio may have been the most long-lived. In a handbook on tuberculosis control published in 1942, Chadwick and Pope recommended this 9:1 ratio as a guide to public health officials in planning their tuberculosis control programmes.10
As the word ‘community’ in the Demonstration's full title implied, a major goal was to increase the town's interest in and support of a first class public health department. After a sickness survey identified many problems that needed attention, nurses and other personnel were added to the staff. The annual budget rose from 
40 cents per capita to $2 per capita.8 All municipal health services were increased. Three infant health clinics were added to the one already in existence. School health services were provided by full-time nurses and physicians, and a dental clinic was established. The leading industries added medical and nursing services. One of these industrial clinics was so impressive that it attracted national attention.
In addition to the case-finding programme among adults, tuberculin testing of young children was done, using the von Pirquet technique of scarification through a drop of concentrated old tuberculin. Approximately 500 children between the ages of 1 and 7 years of age were tested. One-third were positive reactors, with that proportion rising to 46% in the age group 6–7 years.3 This proportion suggests that the average annual infection rate could be as high as 9% per year, a rate of increase rarely seen anywhere in the world today.
One of the environmental measures had immediate and measurable results. This was tuberculin testing of dairy cattle. When it was reported that one-fifth were positive reactors, an educational campaign quickly increased the proportion of pasteurized milk in the town's supply from 15 to 80%.3 Pasteurization of milk undoubtedly contributed to the drop in the infant mortality rate from 81 deaths per 1000 live births in 1916 to an average of 49 in 1922–23.3
Some 90 years later, it seems reasonable to ask what the impact of the Demonstration's finding was on the control of tuberculosis elsewhere. In its summary of the Demonstration in 1952, the Company claimed that ‘the concept of the community demonstration, for which Framingham was the model, was itself a significant contribution to public health and administration. The method has since been adopted widely in attacking tuberculosis and other disease problems over a wide area.’3 Six subsequent research or demonstration projects were listed for which the Demonstration was considered to be either the prototype or the source of valuable suggestions. I know of two of these, the Milbank Foundation's studies in Cattaraugus County, NY and the Rockefeller Foundation's demonstration in Hagerstown, MD. The Milbank studies are known to me through its publications11,12 and the Hagerstown Demonstration through my review of historical documents while I was the director of its successor, the Johns Hopkins Training Center for Public Health Research.13 Although the founders of both studies are very likely to have known of the Framingham Demonstration, I can document this only for the Milbank studies.12
A major achievement of the Demonstration was the improvement of the town's tuberculosis rates to levels appreciably below those of the similar control towns. That this could be done by case-finding and treatment supplemented by pasteurization of milk apparently went unnoticed or ignored in spite of the responsibility of the National Association for the Study and Prevention of Tuberculosis to analyse and report the findings of the Demonstration. Only the Metropolitan Life Insurance Company appears to have grasped the message. They quickly made case-finding and treatment of active cases available to all their employees.3
Unfortunately, the only durable contribution to tuberculosis control in other communities was the observation that there were nine active cases for each annual death. Even that estimate was rendered irrelevant after the advent of mass chest X-ray surveys in the mid-1940s.
The Framingham Community Demonstration is the prototype of a truly participatory community-based study and is probably the first in what has recently become a torrent of publications on this topic that requires 250 pages to summarize.14 Framingham is not mentioned in any of its indices nor in a historical review of community-based research.15
It is hoped that reprinting an early paper from the first Framingham study and the accompanying commentaries will rescue it from the dustbin of history. It still has value for epidemiologists, sociologists, and public health planners.
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Acknowledgments |
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The author thanks Dr Anthony J Alberg and Drs Daniel and Martha Williams for helpful comments.
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References |
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 Top References |
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1 Oppenheimer GM. Becoming the Framingham study 1947–1950. Am J Public Health 2005;95:602–10.
2 Dawber TR. The Framingham Study. The Epidemiology of Atherosclerotic Disease. A Commonwealth Fund book. Cambridge, MA: Harvard University Press, 1980.
3 Dublin LI. A 40 Year Campaign against Tuberculosis. New York: Metropolitan Life Insurance Company, 1952.
4 Gordon T, Kannel WB. The Framingham, Massachusetts, study twenty years later. In Kessler II, Levin ML (eds). The Community as an Epidemiologic Laboratory. Baltimore: The Johns Hopkins Press, 1970.
5 Daniel TM. Captain of Death: The Story of Tuberculosis. Rochester: University of Rochester Press, 1997.
6 Linder FE, Grove RD. Vital Statistics Rates in the United States 1900–1940. Table 20, Specific Death Rates for Selected Causes, by Race, Death Registration States and Each State, 1900–1940, Every Fifth Year. Washington: United States Government Printing Office, 1947.
7 Armstrong DB. The Framingham Health and Tuberculosis Demonstration. Am J Public Health 1917;7:318–22.
8 Armstrong DB. The medical aspects of the Framingham Community Health and Tuberculosis Demonstration. Am Rev Tuberc 1918–1919; 2:195–206. (Reprinted Int J Epidemiol 2005;34:1183–87.)
9 Armstrong DB. Four years of the Framingham Demonstration. Am Rev Tuberc 1921;4:908–19.
10 Chadwick HD, Pope AS. The Modern Attack on Tuberculosis. New York: The Commonwealth Fund, 1942.
11 Downes J. Salient points of attack against tuberculosis. Milbank Mem Fund Q 1940;18:44–60.[CrossRef]
12 Armstrong DB. The Tuberculosis Demonstration plans of the Milbank Memorial Fund. Am J Public Health 1923;13:14–16.
13 Comstock GW, Bush TL, Helzlsouer KJ, Hoffman SC. The Washington County Training Center: an exemplar of public health research in the field. Am J Epidemiol 1991;134:1023–29.
14 Viswanathan M, Ammerman A, Eng et al. Community-based participatory research: Assessing the evidence. Evidence Report/Technology Assessment No. 99. AHRQ Publication 04-E022-2. Rockville MD/Agency for Healthcare Research and Quality, 2004.
15 Israel BA, Schultz AJ, Parker EA, Becker AB. Review of community-based research: assessing participatory approaches to improve public health. Annu Rev Public Health 1998;19:193–202.
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