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HIGH BLOOD PRESSURE
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Washington Hilton Hotel
January 15,1973

Washington, 0.0.

DHEW Publication No. (NIH) 73-486

 

, Ington, D.C. 20402
PO Bookstore

I 973
PaBL/C
HEMW

Table of Contents

Prepared for the

National High Blood Pressure Education Program
1, me

NaflonalHean and Lunglnsthute

Bethesda, Md. 20014

”"WRS

 

TABLE OF CONTENTS

 

Page
INTRODUCTION
Introduction. ...... 1
Theodore Cooper, M. D.
Director

National Heart and Lung Institute

Introductory Remarks 3
Robert Berliner, M.D.
Deputy Director for Science
National Institutes of Health

PRESENTATIONS

KeynoteAddress.... ..... . .. 5
"Hypertension: The Indictment and the Challenge"

The Honorable Elliot L. Richardson

Secretary of Health, Education, and Welfare

ConferenceAddress........... . ...... . . ........ 10
”High Blood Pressure in the U. S. — An Overview of the
Problem and the Challenge"

Jeremiah Stamler, M.D.

Professor and Chairman

Department of Community Health and Preventive Medicine

Professor, Department of Medicine

1 Northwestern University Medical School

LuncheonAddress.. ...... . . ........ ...... 66
”The Prognosis for High Blood Pressure"

Charles C. Edwards, M.D.

Commissioner

Food and Drug Administration

RE SPONDE RS

Labor ..... 72
"Labor-Related Social and Public Policy Issues in the
National Hypertension Information and Education
Program"
Leo Perlis
Director
Department of Community Services
AFL-CIO

Page

Practicing Physicians........................................ 76
"Hypertension and the Practicing Physician"

Ray W. Gifford, Jr. , M.D.

Director

Department of Hypertension and Nephrology

Cleveland Clinic

Consumer.... ...... 80
"Consumer—Related Issues in the National Hypertension
Information and Education Program"
Earlean Lindsey
Community Organization and Resource Specialist
Mile Square Health Center

MedicalEducation............................................. 83
"Hypertension and Medical Education"

J. Willis Hurst, M. D.

Professor and Chairman

Department of Medicine

Emory University

Insurance and Occupational Health 89
"Insurance, Occupational Health, and Hypertension"

Leon J. Warshaw, M.D.

Vice President and Chief Medical Director

Equitable Life Assurance Society of the United States

Media 93
"Media-Related Aspects of the National Hypertension
Information and Education Program"
Thomas J. Deegan, Jr.
President
Thomas J. Deegan Co. , Inc.

APPENDICES

Agenda. ..... 98

Advisory Committee Members................................ 102

ii

Introduction

 

 

INTRODUCTION
Theodore Cooper, M.D. *

I would like to take this opportunity to welcome you all to the National Conference
on High Blood Pressure Education. We are meeting today as a result of Secretary
Richardson's initiative last July, which launched a high blood pressure program in which
educational aspects have the highest priority. The program developed following a con-
ference of private and government groups interested in high blood pressure held at the
National Institutes of Health. This meeting recommended action upon such points as:

. . .Expansion and coordination of efforts.

. . . Continuing research into high blood pressure causes, population patterns,
and instrument and drug development.

. . . Improvement and expansion of public and professional education about high
blood pressure.

Two committees were appointed and have been hard at work through special
meetings, projects and task forces in developing plans and activities of the Program.
One of the two committees, the Hypertension Information and Education Advisory Com-
mittee, consists of 12 members from medicine, communication, education, and the
general public. The second committee consists of representatives from the National
Institutes of Health, Health Services and Mental Health Administration, the Food and
Drug Administration, and the Veterans Administration. This Inter-Agency Working
Group on High Blood Pressure serves to coordinate the federal government's efforts in
our new program.

The Advisory Committee and Inter-Agency Working Group have been combined
to form four task forces, which correspond to the working areas in our program. The
first task force concerns itself with identifying acknowledged methodology for taking blood
pressures, criteria for screening, criteria for treatment, and evaluation. This task
force is working closely with the various professional organizations that have interests
similar to their own.

The second task force deals with the various aspects of what is needed to mount

 

* Director, National Heart and Lung Institute, Bethesda, Maryland

a national program for professional education, and the third task force is looking into
the problems and responsibilities in initiating a community education program. The
fourth task force has the unenviable job of attempting to assess the impact of a major
high blood pressure education program on the health care delivery system in the United
States.

The Conference today, we hope, will serve many functions. Secretary Richardson
will deliver the Keynote address, and will describe the character of the federal involve—
ment in our effort. Dr. Stamler will outline the magnitude of the problem, and our
responders in the afternoon will give their unique points of view as they represent the
various sectors of the national community. With this Conference, we wish to publicly
inaugurate the hypertension education program planning effort, to obtain your viewpoints
as you represent your own constituencies, to encourage the exchange of ideas among the
planners of the national program and the representatives here today, and to stimulate
the application of present resources to the screening, treatment, and follow-up of one

of the most serious and prevalent public health problems we have today.

INTRODUCTORY REMARKks
Robert W. Berliner, M.D. *

I would like to welcome you to this National Conference on High Blood Pressure
Education. While the logistical support for arranging this conference was provided
by the National Institutes of Health, the National Hypertension Information and Educa-
tion Program is a combined effort among several government agencies — the Food
and Drug Administration, the Health Services and Mental Health Administration, the
Veterans Administration, and the National Institutes of Health — in cooperation with
a number of private organizations — the American Heart Association, the American
Medical Association and the National Medical Association.

We invited representatives from some 80 organizations, and approximately 65
are participants here today representing the medical, nursing and allied health pro-
fessions; organized labor and citizen—consumer groups. The objectives of this con—
ference are several:

To focus national attention on hypertension as a public health problem;
To inaugurate the Hypertension Education Program planning effort;

To obtain viewpoints from various sectors of the community concerning

problems in the development and implementation of educational programs;

To identify areas of contribution from various sources for implementation

of the National Hypertension Education Program;

Finally, to identify problems and opportunities in implementing community
control problems.
I am particularly pleased to be a participant in this meeting. In 1950, less than
a mile from here, another meeting that had to do with hypertension, at least in part,
was held. It was the first National Conference on Cardiovascular Diseases. Having
only recently arrived at the National Institutes of Health to join a research team being

organized by Dr. James Shannon, I viewed the 1950 Conference and what it had to say

 

* Deputy Director for Science, National Institutes of Health, Bethesda, Maryland

about hypertension with more than casual interest. At that conference a distinguished
committee considered the case of hypertension, the state of research, training, and
the application of knowledge. All of this took a meager six pages in the conference's
proceedings —— and pointed up the need for additional research and the abysmal lack
of clinical knowledge in this area.

There was the merest hint, almost subliminal, that anything like effective treat-
ment was lurking beyond the horizon. Nonetheless, research brought such clinical
progress that Jim Shannon was able to predict, about the time of the dedication of the
NIH Clinical Center in 1953, that some effective clinical measures against hypertension
were about due. They did, indeed, come, and there came also, in recent years, the
proof of the hypothesis that reduction of persistent high blood pressure could reduce
the incidence of hypertension's sequelae such as strokes and kidney failure.

It was, however, in a very real sense the concern and interest of Secretary
Richardson that brought the matter of hypertension to the professional and public atten-
tion of which this conference is a manifestation. He determined quite rightly that the
time had come for action. He also decided that the need was not for a massive Federal
program, but rather for a vigorously expanded endeavor of the private and public sec-
tors in a partnership whose effect upon the problem of hypertension would be accom-
plished at the local community level through local medical societies, heart associations,
health departments, and through the participation of local citizen-consumer groups.

Thus, just six months ago, Secretary Richardson announced the launching of the
National Hypertension Program — and has provided both the needed impetus and catal-
ysis for a major enterprise in the field of high blood pressure and hypertensive heart
disease. He has held that the understanding on the part of both the physician and his
current or potential patient is indispensable and that the first major task is to inculcate
such understanding. This conference is a means to that end.

There could be no better keynoter than Mr. Richardson himself. It is most
fitting and proper that the theme of the National Conference on High Blood Pressure
Education should be sounded by the man who has conceived and supported this program.
I am honored to introduce to you the Honorable Elliot L. Richardson, Secretary,

Department of Health, Education, and Welfare.

Presentations

 

HYPERTENSION: THE INDICTMENT AND THE CHALLENGE

The Honorable Elliot L. Richardson *

I am encouraged — in the literal sense that it will do my heart good — to be a
part of this first National Conference on High Blood Pressure Education. Being a
somewhat privileged witness today, I can enjoy dual status as an observer and as one
giving testimony, although I cannot in the latter role claim the title of expert. I am,
however, an enthusiastic advocate of our joint endeavor.

The cause which brings us together is a good one, and the prospects of success
are as great as our determination. A visitor to this country during the last century,
Alexis de Tocqueville, marveled at the positive attitude of the typical American, who
would insist that "what is not yet done is only what he has not yet attempted to do. "
This national can-do approach to life has yielded many accomplishments. It has taken
men to the moon and - in cooperation with medical scientists of other nations — has
vanquished the polio virus. But the habit of success appears to have made us extremely
impatient about facing up to the ills that still beset our society.

Our very frustration can be constructive if it spurs us to overcome problems, but
destructive if it makes us yield to a compulsion to grab at the quickest remedy dangling
before us, no matter how much it costs or how temporary the relief it brings. If I
have learned anything in a decade of Federal service, it is this: Because every
important national action involves hard decisions, we mustbe deliberately selective
and make the most balanced, the most realistic, and the most humane choices we can
or else constantly court failure and disillusionment.

Six months ago we announced a new, comprehensive program which I believe
meets all of the criteria of balance, realism and humaneness. This fresh approach —
this new crusade — is being mounted against a powerful but insidious enemy. Our
assault is bold, exuberant and idealistic in its goals, but surprisingly modest, econom-
ical and practical in its monetary requirements. The National Hypertension Program
is directed at a problem about which we rightly should be impatient and aggressive -—

not only because it affects the health, the well—being, and the very life of so many

* Secretary of Health, Education, and Welfare
5

people, but also because it is a problem with which the state of the art and science

of modern medicine already has demonstrated an impressive ability to cope. Yet
millions of our fellow citizens are not getting the full benefit of this medical knowledge
and skill.

Therein lies an indictment and a challenge. The indictment cannot be denied,
but the challenge has been accepted and a program is underway to fulfill the mutual
obligations we have assumed. I am happy today to report that this undertaking has
progressed far in the six months since it was launched. Even at the initial meeting
last July, which was preceded by a great deal of staff work on the part of governmental
and private health organizations, we were able to describe our objectives and begin
Working toward them.

Our objectives are implicit in an alarming set of facts. Briefly — and without
undue recitation of mournful numbers —- we note that hypertension begins to claim its
victims even before they reach adulthood. The threat increases with each additional
year of life. There are some 23 million Americans — more than one in ten — who now
have high blood pressure. Of these, 60 thousand die every year as a direct result of
their disease. In addition, hypertension is an underlying cause of more than a million
heart attacks and strokes which occur annually in this country, killing or making
invalids of their victims. Many of you, in formal presentations and floor discussions,
will be filling out the statistical dimensions of the hypertension problem during our
conference today.

By any measure, it is indeed an understatement to term hypertension one
of our foremost health hazards. The problem is compounded by the fact that at least
half of the people who have "high blood pressure are not even aware of it. Damocles,
as he sat at a banquet table in ancient Greece, at least had the advantage of knowing
about the sword that hung by a single hair above his head. Yet here, in twentieth-
century America, millions of people are sitting or walking around quite unaware that
their bodies carry hidden time bombs ticking toward the moment of detonation.

A note of tragic irony is added when we realize that, in our time and place,
there are plenty of experts available to defuse, or at least restrain, such bombs

rather simply and effectively if they are consulted in time — and if their prescriptions

are faithfully taken. Hypertension can be brought under control by proven treatment
which is neither unduly hazardous, expensive, or complicated. This has been demon-
strated quite dramatically through the work of Dr. Edward D. Freis of the Veterans
Administration, and has been borne out in the individual experience of thousands of
private physicians and their patients.

The objectives derived from the facts of hypertension are being pursued through
a broad-based program. We realize that, first of all, people must be informed about
the problem — it may be their problem or that of the persons closest to them — and
educated about the benefits of identifying and treating it. From this knowledge we
hope for — and we will work to insure — follow—up action: Action on the part of in-
dividuals who will volunteer to have their blood pressure checked periodically; and
action on the part of doctors, nurses and paraprofessionals who will be encouraged
to include, with greater consistency, blood pressure readings in any routine exami—
nation — and more consistently take appropriate action when those readings are not
within the normal range.

I might add parenthetically that I am so interested in this matter that I have
learned, under the tutelage of Dr. Ted Cooper, how to take his blood pressure as well
as my own, and we taped some public service television spots recently while so en—
gaged. Incidentally, it was with considerable relief that I learned that we're both in
good shape as far as blood pressure is concerned.

The screening and detection activities we envision, and the necessary follow—
up treatment, will involve whole communities — not only practicing physicians,
medical educators, and other health-related career personnel, but also members of
the insurance industry, representatives of public communications media, of labor
organizations, and of consumer groups. It is no coincidence that we have represent—
atives of precisely these half-dozen groups on today's agenda to provide their well-
informed advice and viewpoints as we move ahead on this campaign against hyper-
tension. The list of categories of concerned citizens is much more comprehensive
than these six groups, of course, as indicated by the 75 or so organizations repre—
sented at this conference. This is intended to be an all-inclusive movement, and we

hope more and more people will be enlisted in the battle against hypertension.

Two committees have been working diligently since July. One of these is the
Hypertension Information and Education Advisory Committee, which includes
physicians from a wide spectrum of specialties and locations as well as several ex-
perts in communications and advertising. The other is an Interagency Working Group
composed of representatives from the National Institutes of Health, the Health Services
and Mental Health Administration, the Food and Drug Administration, and the Veterans
Administration. The Working Group is coordinating the efforts of these agencies and
promoting an exchange of information. One of its missions is to provide, for physicians
and others, a focal point within the government for reliable information about hyper—
tension. As you know, its chairman is Ted Cooper, Director of the National Heart
and Lung Institute.

Both of these committees have been successful in encouraging wider- discussion
and more intensified activities concerning high blood pressure. We do not measure
their performance in terms of their growing files and ringing telephones, but by such
factors as the interest generated in the communities and in the nearly four dozen groups
represented here today. Eventually they — and all of you — will be able to gauge
achievements according to the most impressive scale of all: The saving of thousands of
lives and the enjoyment of millions of days of good health.

As we see it, the government can contribute most toward a nationwide decline
in hypertension by serving as the focus, the catalyst — or perhaps, in organizational
terms in" the first stages — as the home office. But we believe the moving force be—
hind this effort will be generated by health professionals and public-spirited, non-
professional activists all over the country. I am confident that, in the years ahead,
the hypertension program will be regarded as an instance of preventive medicine at
its best — a landmark campaign against a disabling, deadly disease. It can, I believe,
pave the way for future national attacks on other major health problems that are, or
will become, preventable and controllable.

Of course, the more successful we are in this program, the more difficulties
we will be creating — in one sense — for the health care community. That is, in
order to solve a tremendous national health problem, we must be willing to meet a

lot of smaller problems related to the growing demand for medical services Which we

hope to stimulate. But the medical personnel and facilities of this country are, I
am convinced, equal to the challenge, particularly if they have our help.

Actually, if we do the screening job properly, private and public health care
systems need not be overburdened. We shall have to rely heavily on lay people not
only to take blood pressure in industrial, school, and public settings, but also to refer
to physicians for further diagnosis or treatment only those persons with abnormal
readings. I am sure that if Dr. Cooper can teach me to read blood pressure, physicians
around the country will be able to teach other laymen to do this.

I have remarked before that I leave the Department of Health, Education, and
Welfare with mixed emotions. It is just such challenges and opportunities as those
represented in the hypertension program that I am most reluctant to leave behind. Let
me assure you, however, that my changing responsibilities will neither dim my
interest in your efforts, nor curb my willingness to be of whatever assistance I can.

In closing, may I offer you a few words of advice appropriate to the tremendous job
you face as participants in this first National Conference — words that might serve as

your campaign motto: Ladies and gentlemen, roll up your sleeves.

 

HIGH BLOOD PRESSURE IN THE UNITED STATES —
AN OVERVIEW OF THE PROBLEM AND THE CHALLENGE

Jeremiah Stamler, M. D.*

Hypertensive disease, mass public health problem — its prevalence in the United
States by age, sex and race:

 

Hypertensive disease is a mass public health problem in the United States —
one of the most important, if not file most important affliction producing premature
sickness, disability and death in our adult population. The data collected a decade
ago by the National Health Examination Survey of the Public Health Service — data on
a random sample of the U.S. adult population age 18—79 —— indicate that about 15 per-
cent of whites and 28 percent of blacks have high blood pressure (based on World
Health Organization criteria, systolic 2160 and/or diastolic 295 mm. Hg) (Tables 1
through 3). The disease is widely prevalent among all strata of the adult population —
low, middle and upper income; North, East, South and West; less and more educated;

residents of central metropolises and their suburbs, of small cities, of rural areas.

Data consistent with these National Health Examination Survey estimates have
been repeatedly reported by local surveys. The recent findings of the Chicago Heart
Association Detection Project in Industry — collected from .1967 to 1972 on over 35, 000

employees of almost 100 companies — are typical (Figure 1).
A sound current estimate is that 20 to 25 million Americans have hypertension.

As the accompanying data make clear, high blood pressure afflicts not only the
elderly, but also young and middle—aged adults — people in the prime of life, in the
most productive years. The National Health Examination Survey data yield estimates

that at age 25-34, 3.7 percent of white men and 12.5 percent of black men, 2.3 percent

* Professor and Chairman, Department of Community Health and Preventive Medicine;
Professor, Department of Medicine, Northwestern University Medical School,
Chicago, Illinois

11

of white women and 8. 5 percent of black women are hypertensive (Table 1). The preva—
lence rates rise steadily with age. At all ages up to 80, they are conspicuously higher
for blacks than for whites. Overall the ratio is about two—to—one — prevalence rates
twice as high for blacks as for whites. And hypertension — when present — tends to
be more severe in blacks than whites. Thus, as shown in Table 3, about twice as many
blacks as whites have diastolic pressures of 90 mm. Hg and greater, but for severe
hypertension — e.g. , diastolic levels of 115 and above — the relative rate is 3. 3 times
as high for black men compared to white men, and 5. 6 times as high for black women
compared to white women.

Table 1. Percent of white and Negro adults with blood pressures of

at least 160 systolic or 95 diastolic, by sex and age: United
States, 1960—62 (National Health Examination Survey)

 

 

 

 

 

 

 

Systolic at least Diastolic at least Systolic at least 160
160 mm. hg. 95 mm. lag. mm. hg. or diastolic
Sex and Age 95 mm. hg.
White Negro White Negro White Negro
Percent
Both sexes - 18-79
years ----------------------- ““5 ALS 8.7 gm 14.7 27.6‘
Mg
Total - 18-79 years ----------------- 8. 6 16. 8 9. 1 22.6 13. 6 27.6
18-24 years ---------------------------- 0.2 _ 1.7 1.9 1.7 1.9
25-34 years ---------------------------- 0.7 4.6 3.4 11.5 3.7 12.5
35-44 years ---------------------------- 3. 9 16. 2 10. 9 25. 9 11. 8 26. 5
45-54 years-------— -------------------- 8.7 10.8 13.8 29.5 17.3 30.8
55-64 years ---------------------------- 15.9 29.4 11.9 31.6 21.4 44.6
65—74 years ---------------------------- 26. 1 63.2 12. 3 40. 5 27.3 66. 0
75-79 years ---------------------------- 39. 1 59.8 13.3 21.2 40.2 59.8
Women

Total - 18-79 years ----------------- 12.8 20.4 8.3 21.5 15.6 27.6
18-24 years ---------------------------- __ 0.7 0.8 3.4 0.8 3.4
25-34 years ---------------------------- 0.7 3.4 2.1 8.5 2.3 8.5
35-44 years ---------------------------- 2. 3 14. 3 5. 3 24. 1 6.2 25.6
45-54 years ---------------------------- 10. 7 30.8 10.9 34.3 15. 5 41.9
55-64 years ---------------------------- 25.3 33.8 16.4 36.7 31.0 41.0
66-74 you-s ---------------------------- 45.4 68.5 17.9 32. 1 48.6 71.0
75-79 ye... 42.7 69.4 12.0 26.3 44.9 69.4

 

 

 

 

 

 

 

 

 

12

Table 2. Number and percent distribution of systolic, blood pressures
for white and Negro adults, by sex: United States, 1960-62
(National Health Examination Survey)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Men Women Men Women
Pressure in mm. hg.
White Negro White Negro White Negro White Negro
Number of persons in thousands Percent distribution

Total --------------- 46,561 5,195 51,184 6,219 100.0 100.0 100.0 100.0

Under 90 ------------------ 43 - 167 18 0 .1 - 0 . 3 0 .3
90-99 --------------------- 584 99 2,258 196 1.3 1.9 4.4 3.1
100-109 ------------------- 3,517 434 7,566 825 7.6 8.4 14.8 13.3
110-119 ------------------- 8,866 955 11,655 1,333 19.0 18.4 22.8 21.4
120-129- ------------------ 11,287 920 9,432 919 24.2 17.7 18.4 14.8
9,290 814 6,813 698 20.0 15.7 13.3 11.2

5,558 571 4,296 536 11.9 11.0 8.4 8.6

3,382 ‘ 522 2,676 420 7.3 10.1 5.2 6.8

1,734 319 2,047 370 3.7 6.1 4.0 6.0

170-179-- 1,060 249 1,467 246 2.3 4.8 2.9 3.9
180-189 ------------------- 447 157 1,085 236 1.0 3.0 2.1 3.8
190-199 ------------------- 416 86 843 127 0.9 1.6 1.6 2.0
200-209 ------------------- 214 34 465 61 0.5 0.7 0.9 1.0
210-219 ------------------- 74 - 172 152 0.2 - 0.3 2.4
220-229 ------------------- 53 25 91 25 0.1 0.5 0.2 0.4
230-239 ------------------- 27 - 88 19 0.1 - 0.2 0.3
240-249 ------ - — 11 - - - 0 .0 -
250-259 ------ 9 9 13 - 0.0 0 2 0.0 -
260+ ---------------------- - - 36 36 - - 0.1 0.6
160+ 4,034 879 6,318 1,272 8.8 16.9 12.3 20.4
2201' 89 34 239 80 0.2 0.7 0.5 1.3

For young, middle—aged and elderly adults, men and women, white and black,
a high proportion with hypertension have evidence of heart involvement — hypertensive
heart disease (Figure 2 and Table 4). That is, not only is their blood pressure abnor-
mally high, but also medical examination reveals evidence of cardiac abnormality ——
e.g. , on electrocardiogram and/or chest x—ray — even though the person frequently is
still free of symptoms. When the disease has gone this far, risks of serious sickness,
disability and death are even greater than when elevated blood pressure only is present,
without evidence of heart disease. A comparison of the data in Tables 1 and 4 indicates
that among hypertensives, definite hypertensive heart disease is present in from 48

percent (white men) to 80 percent (black women). \

\

\
In keeping with the tendency of hypertension tb be not only more prevalent, but
also more severe among blacks than whites, hypertensive heart disease is present at

\
rates three, four, seven even nine times greater for blacks of a given age-sex group

compared to whites of the same age—sex group (Table 4).

13

Table 3. Number and percent distribution of diastolic blood pressures
for white and Negro adults, by sex: United States, 1960-62
(National Health Examination Survey)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

   

 

      

 

 

 

 

Men Women Men Women
Pressure in mm. hg.
White Negro White Negro White Negro White Negro
Number of persons in thousands Percent distribution
46,561 5,195 51,184 6,219 100.0 100.0 100.0 100.0
490 43 314 , 25 1.1 0.8 0.6 0.4
367 42 552 93 0.8 0.8 1.1 1‘5
846 108 1,573 74 1.8 2.1 3.1 112
2,362 167 3,619 279 5.1 3.2 7.1 4.5
5,094 461 6,698 714 10.9 8.9 13.1 11.5
6,689 686 8,636 680 14.4 13.2 16.9 10.9
9,807 722 9,364 976 21.1 13.9 18.3 15.7
7,191 686 7,923 891 15.4 13.2 15.5 14.3
5,936 598 4,999 706 12.7 11.5 9.8 11.4
3,520 507 3,250 441 7.6 9.8 6.3 7.1
2,023 638 1,819 457 4.3 12.3 V3.6 7.4
990 182 1,132 243 2.1 3.5 2.2 3.9
663 108 616 221 1.4 2.1 1.2 3.6
110—114 ------------------- 243 132 191 99 0.5 2.5 8.4 1.6
115-119 ------------------- 162 55 234 145 0.3 1.1 .5 2.3
120—124 ------------------- 80 27 109 52 0.2 0.5 0.2 0.8
125-129 ------------------- - 25 64 83 - 0.5 0.1 1.3
130-134 ------------------- 49 - 18 14 0.1 - 0.0 0.2
135+- --------------------- 48 9 72 24 0.1 0.2 0.1 0.4
90+ 7,778 1,683 7,505 1,779 16 6 32.5 14.6 28.6
95+ 4,258 1,176 4,255 1,338 9 0 22.7 8.3 21.5
115+ 339 116 497 318 0 7 2.3 0.9 5.0
PREVALENCE
RATE PER 1,000 483
- E WHITE MEN
400— IIIIIIII BLACK MEN 351 363 358
- E WHITE WOMEN E
300- :2 BLACK WOMEN 260 g
200- 206 E
I40 :57 I49 2
I00 100 87 ‘E'
__ =
E as 52 H E
C) .’1 *7 , ,"’ ===
25-34 35-44 45-54 55-64

4.946 I .885 4,383 2.233 4.238 3.816
426 66 2 306 407 259

NUMBER OF SCREENEES

CRITERION: SBP 2160 AND/OR DBP z 95 mm. 14%.
PREVALENCE RATES AGE-ADJuSTED BY s-VEAR AGE GRO Ps T0 CORRESPONDING
sex-RACE GRouP IN us. POPULATION, 1960.

Figure 1. Prevalence of high blood pressure by age-sex-race, Chicago
Heart Association Detection Project in Industry, November
1967 - May 1972 >

ISO

14

RATE PER
1 .MO
POPULATION

— mm Illllll
lllllmlllll Whil- blank!
— Non-whit. ml...

0.....- Non-whit. {on-loo

 

20 30 40 50 60 1O .0
AGE IN YEARS
Figure 2. Prevalence of definite hypertensive heart disease among adults

by sex and color, United States, 1960—1962 (National Health
Examination Survey)

Morbidity, disability and mortality due to hypertensive disease:

Hypertensive disease is a serious mass public health problem — despite the

fact that at any given time a majority of persons with it are symptom-free. This is so

because they are nonetheless at markedly increased risk of experiencing major cardio-

vascular events (especially heart failure, heart attack, stroke, kidney failure) with

resultant chronic illness and disability. Moreover, young and middle—aged adults with

hypertension are at markedly increased risk of dying prematurely from cardiovascular

"complications. " This is true even for persons with only slight elevations of blood

15

Table 4. Prevalence of definite and suspect hypertensive heart disease
for white and Negro adults, by age and sex: United States,
1960-62 (National Health Examination Survey)

fl?”

 

 

 

 

ge en ~ Women

White I Negro White I Negro

Definite hypertensive heart disease Percent of specified population group
Total 18—79 ears ------------------- 6.5 19.1 9-8 22.2

y J

18-24 years ------------------------------- 0.2 1.9 1.6
25—34 years ——————————————————————————————— 1.1 5.2 0.7 4.7
35—44 years ------------------------------- 4.0 15.2 2.7 14.0
45—54 years ——————————————————————————————— 7.7 24.4 6.8 31.5
55—64 years ------------------------------- 11.7 33.1 19.5 46.4
65-74 years ------------------------------- 16.3 50.2 37.5 66.4
75-79 years ------------------------------- 24.0 32.3 37.1 69.5

Suspect hypertensive heart disease

Total 18—79 years ------------------- 5.0 7.6 3.3 4.7
18—24 years ------------------ ' ------------- 1.5 1.5 __ __
25—34 years ------------------------------- 1.2 7. 3 0. 7 __
35-44 years “"""“'"“"“"'“"‘"". 4. 0 6. 2 0. 8 3. 6
45—54 years ——————————————————————————————— 4.3 10.5 3.4 5.9
55—64 years ------------------------------- 7.3 13.8 8.5 15.0
65-74 years ------------------------------- 13.8 __ 8.4 10.3
75-79 years ------------------------------- 15. 7 21. 4 10. 7 14.2

 

 

 

 

 

 

 

pressure. (I deliberately avoid use of the term "mild" and "benign" hypertension be—
cause they are disarmingly misleading and have blocked proper understanding of the
seriousness of the problem among both the general public and health professionals,
including physicians.) For decades a loud and clear message on this matter has been
forthcoming from the insurance industry. Table 5 — from the Society of Actuaries'
most recent (1959) study — clearly demonstrates the increased risk of premature
death for persons with lesser degrees of hypertension. It shows, for example, that
men age 35 with a blood pressure reading of 142/90, without any concomitant impair—
ments, experienced a survival rate of 80.6 percent over the next 20 years, compared
to 89.0 percent for normotensive standard risks. That is, this ”modest" elevation of
blood pressure — all too frequently treated as insignificant and ignored by clinicians —
was associated with a 76.4 percent higher mortality rate in middle age (19.4 percent

vs . 11. 0 percent).

16

Table 5. Survivorship of applicants for life insurance who showed elevated blood
pressure readings at the time of medical examination for insurance
(1959 Build & Blood Pressure Study, Society of Actuaries)

 

 

 

 

 

 

Age 35 Age 45 Age 55
% Surviving, End of % Surviving, End of ‘7 Surviving, End of
5 yr. 10 yr. 15 yr. 20 yr. 5 yr. 10 yr. 15 yr. 20 yr. 5 yr. 10 yr. 15 yr. 20 vr.
Standard Risks 98.6 96.6 93.5 89.0 96.8 92.1 85.9 77.5 93.3 84.] 71.8 56.0
Risks with Blood Pressure
Reading of Men without Known Minor Impairments

132/85 98.4 95.9 92.2 86.9 96.3 91.0 84.0 74.6 92.3 82.0 68.3 51.2

132/90 98.0 94.9 90 3 83.9 95.8 89.9 82.1 71.8 91.3 79.9 64.9 46.8

142/85 97.9 94.8 90.0 83.4 95.3 88.8 80.2 69 1 90.3 77.8 61.7 42.8

142/90 97.5 93.8 88 2 80.6 94.7 87.3 77.8 65.6 89.1 75.1 57.6 37.9

142/95 97.0 92.5 85.8 76.8 93.9 85.6 74.9 61.5 87.5 71.8 52.9 32.6

152/85 97.4 93.6 87.9 80.1 94.2 86.3 76.0 63.1 88 1 73.1 54.7 34.6

152/90 97.0 92.5 85.8 76.8 93.6 84.9 73.7 59.9 86.9 70.6 51.1 30.6

152/95 96.3 90.9 63.0 72.4 92.8 83.1 70 9 56.1 85.3 67.5 46.9 26.3

162/90 __ __ __ __ 92.5 82.4 69 8 54.7 84.7 66.3 45.3 24.7

162/100 __ __ __ __ 90. 5 78. 1 63 1 46 1 80.9 59.0 36. 1 16.4
Risks with Blood Pressure

Reading of Men with and without Known Minor Impairments

132/85 98.2 95.6 91.6 85.9 96 1 90.6 83.3 73.7 92.0 81.3 67.1 49.7

132/90 97.7 94.3 89.1 82.0 95 7 89.5 81.5 70.9 91.0 79.2 63.8 45.4

142/85 97.7 94.3 89.1 82.0 95.2 88.4 79.6 68.2 90.0 77.1 60.6 41.5

142/90 97.2 93 0 86.7 78.2 94.6 87.0 77.2 64.7 83.8 74.4 56.7 36.8

142/95 96.6 91 7 84.4 74.6 93 8 85.2 74.3 60.7 87.2 71.3 52.0 31.6

152/85 97.2 93.0 86.7 78.2 93.9 85 6 74.9 61.5 87.5 71.8 52.9 32.6

1.52/90 96.6 91.7 84.4 74.6 93.3 84.1 72.6 58.3 86.3 69.3 49.4 28.8

152/95 96.0 90.1 81.6 70.3 92.5 82.4 69.8 54.7 84.7 66.3 45.3 24.7

162/90 _ __ __ _ 92. 1 81.4 68.2 52.5 83.8 64.6 43.0 22.5

162/100 _ __ _ _ 90. 5 78. 1 63. 1 46. 1 80. 9 59. 0 36. 1 16.4

 

Similar findings have been recorded by the prospective epidemiological re—
search studies carried out in various parts of the United States over the last 20 years.
Figure 3 presents the combined findings of five of these investigations working together
in the national cooperative Pooling Project — the Albany civil servant, Chicago Peoples
Gas Company, Chicago Western Electric Company, Framingham community and

Minneapolis—St. Paul business and professional men's studies .

I might say parenthetically here — and I'm sure you‘ll agree that it is not a
gratuitous statement — that most of the studies being cited here were financed by the
National Heart and Lung Institute. This is one such, a joint project sponsored by the

Institute and the American Heart Association.

These data in Figure 3 deal with 7, 581 white men age 30—59 at first examination.

After exclusion of men with definite coronary heart, they were classified based on their

17

3:?
moon ""57 ““9“ sunneu DEATH
zoo- conomny EVENT ‘88

     

 

 

 

 

 

 

 

 

 

ISO ‘
100—
46
so— 48
.:.:. [3 I1
0 _ .:.:. .o'o.o.1 % @
outsrouc 7s- 95. 95- 7s— 35- 95
manna ‘75 s4 94 .04 '°" ‘75 s4 94 :04 '°“
yffififis 70 no :86 39 so l6 4: so 29 23
5%,?5'5: 1.27: 2.752 2:25 940 493 L27: 2,752 2:25 940 493
Pomunou A 9/70

Figure 3a. Diastolic blood pressure level at entry and ten year incidence
and mortality rates — 7, 594 white males age 30—59 at entry
(Pooling Project)

we
PE I,OOO l$8
ISO ALL CHI) DEATHS STROKE DEATHS ALL DEATHS w-

IOO-

 

 

 

 

 

   

 

so -
o 3 4 4‘ 9 ..-
o— _m_ImL °
DIASTOLIC 75- 85- 95- 7s— 35- 95 5- ss- 95-
PRESSURE ‘75 94 94 m4 “’5’ ‘75 s4 94 m4 “’5’ ‘75 34 4.04109
39395:” as 66 95 39 44 o u u 5 6 73 I65 IBI as 94 ‘
“g“,‘fg: mm 2,752 2,125 940 493 mm 2,752 ms 940 493 mu 2.152 2,125 940 «3
POPULATION A 3”"

Figure 3b. Diastolic blood pressure level at entry and ten year mortality
rates — 7, 594 white males age 30—59 at entry (Pooling Project)

18

diastolic blood pressure level at this single point in time. Levels in the range 95-104
mm. Hg were recorded for 940 of these men (12.4%); another 493 (6. 5%) had levels of
105 mm. Hg or greater. Note that mortality over the next ten years from heart attack,
including sudden death, was twice as high in the group with so—called "mild" hyperten—
sion — diastolic levels of 95-104 mm. Hg — compared to those with normal diastolic
pressures. And the increase in risk of coronary death, including sudden death, was
more than threefold for the group of 493 men with pressures of 105 mm. Hg and
greater. For the most straightforward and crucial index, death from all causes, the
10—year rate was 60 percent higher for men with diastolic pressures 95—104 mm. Hg,
compared to normotens ives, and 200 percent higher for those with hypertension in the
range 105 mm. Hg and greater. Note also the 60 percent greater mortality rate from

all causes even for the men with diastolic pressures of 85—94 mm. Hg.

The data from the Pooling Project also demonstrate one other very important
point: When hypertension coexists with other major risk factors — e.g. , cigarette
smoking, hypercholesterolemia — risks are additive (Figure 4). Thus, men origi-
nally age 30—59 with hypertension as the only risk factor experienced twice as high a
death rate over the next ten years as men with no risk factors . But when hypertension
coexisted with cigarette smoking or hypercholesterolemia (any one only of these two)
risk of dying was more than trebled. And when hypertension was present along with
both these other factors, the death rate was five times higher. These data practically
speak for themselves, in terms of their implications for public health and medical

practice .

Similar data are available indicating that a single blood pressure recorded in a
routine school examination of college entrants — young men in their late teens — is
already very meaningful prognostically (Figure 5). Even that early in life, slight
blood pressure elevation identifies people at greater risk. These are data from a
study done by Dr. Ralph Paffenbarger, of Penn and Harvard students of 20, 30, 40 or
more years ago. He went to their records to pick up data from their college entrance

physical examinations. He then traced these people 20, 30, 40 or more years later,

19

FIRST MAJOR CORONARY
RATE EVENT . ,
PER LOOO 7 L249 a: NONE
3,320 m ONE ONLy

         

l50— 2.!78 E TWO ONLY
595 [11] ALL THREE
IOO—
SUDDEN DEATH
8
50— 4 42
2° 30
E3}. 7 '3
0— ..;."° [2.5—1.1
NUMBER OF Nofle ONE TWO ALL NONE. ONE TWO ALL
RISK FACTORS ONLY ONLY THREE ONLY ONLV THREE
39355“ 28 m use 82 e 49 66 26

CUTTING POINTS: SERUM CHOLESTEROL a 250 mEtrfil; mfouc BLOOD PREssuRE2 90 mm. Hg;
ANY usE OFCIGARETTEs AT ; POPULATION A. 8/7
0

Figure 4a. Hypercholesterolemia, hypertension, cigarette smoking and ten year

incidence and mortality rates — 7, 594 white males age 30—59 at entry
(Pooling Project)

RATE 1.249 E: NONE
PER I,OOO 3,320 ONE ONLY TOTAL MORTALITY
2,I78 a Two ONLY I47
'50— 595 um ALL THREE

ALL CHD DEATHS

    

      

      

[00* 89.
50—
23 30
I3 ;:;:;:-:
NUMBEROO; ONE Two ALL ONE Two ALL
RISK FACTORSNONE ONLY ONLY THREE “WE ONLY ONLy THREE
Ngcgfitgoe ,7 9, .02 41 44 209 226 85

CUTTING Palms: SERuM CHOLESTEROL 2250 m ./dl.- DIASTOLIC BLOOD PRESSURE .
2 90mm. Hg; ANY use OF- CngAREfTES AT ENTRY; POPULATION A

8/70

Figure 4b. Hypercholesterolemia, hypertension, cigarette smoking and ten year
mortality rates —- 7, 594 white males age 30-59 at entry (Pooling
Project)

20

determined who was currently dead and who alive, and the causes of death, and find-
ings in the college examinations were related to mortality. Systolic pressure at col-
lege entry is one of the variables, and — as evident from Figure 4 — it was evaluated
in a simple way, whether 130 and above, or under 130 mm. Hg. Consider the limita—
tions of this set of data — a single measurement, time of day unknown, relation to
meals unknown, relation to smoking unknown, examiner unknown, position unknown
(lying, standing or sitting) — a motley collection of one—time measurements, unstand—
ardized. Yet the teen-age young men with levels of 130 and above had a 1.6 times
higher mortality from coronary disease over the next decades, compared to those who

were under 130, a 60 percent higher mortality.

   
   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2
>- 3
‘9 b
> E .2 2
MORTALITY g g g‘ f. ..
RATIOS a 5 1 5 .. g x
~67 2 a :3 1. 2' 2 .9
— m n f- 3 '6 E T: 3.
g E E .2 5 '5 g 5 0.7
'- -= - 'z _
PREVALENCE g '3 '3 .3 1? a :5 g g a
g m CONTROLS .z .5 45‘ 2 :3 < z z m .3
None i161614131.3121s16l13
Smoking 10+ cigotettes/doy 15 2.1 1 9 1 8 1 9 2.5 1 8 3 8 1 8
Systolic a? 130+ mm Hg 27 4 g "l 2.3 1.7 1.8 1.4 1.5 1.9 2.1
Height/ Vaweight: 12.8 or less 25 4 7 1.6 1.6 2.0 1.5 2.0 2.0
Body height <68 inches 24 3 6 10 2.1 1.9 1.4 1.5 1.4
A parent dead 16 3 4 4 4 2.0 1.5 2.6 1.4
Without siblings 14 2 4 3 3 2 1.3 1.5 1.4
No varsity athletics 84 13 24 20 22 13 12 1.9 1.4
Emotional index 21 5 7 6 s 3 4 17 = 1.4
Scarlet 1m. 16 2 4 3 4 3 3 13 s

 

 

 

 

 

 

 

 

 

 

Figure 5. Estimated mortality ratios (coronary heart disease) and
prevalence ratios for specified factors assessed during

’college years

21

The data in Figure 5 also permit another look at the combined effect on mor—
tality of elevated blood pressure and cigarette smoking. Like elevated blood pressure,
smoking alone was associated with a 60 percent increase in risk. College entrants
with a systolic blood pressure of 130 or above, and smoking ten or more cigarettes a
day, experienced a 110 percent increase in risk of coronary death. The effects of the
two risk factors are additive. The hypertensive who smokes cigarettes is at greater

risk than the hypertensive who does not.

The implications are self—evident and need to be acted on: Mass public educa-
tion should proceed vigorously not only among adults, but also among our youth —
along with detection. Efforts along these lines have in fact been undertaken by the
Chicago Heart Association both in industry and in high schools (college is really not
the earliest point one can use), to find those really stigmatized by blood pressure ele-
vation, as well as cigarette smoking, gross obesity, hypercholesterolemia. And, of
course, family history of premature disease and early death from adult cardiovascular
disease — hypertensive and/or atherosclerotic — also has predictive significance and
can be detected early. And the index case can and should lead to investigation of the

whole family .

When the person with elevated blood pressure also has signs of hypertensive
heart disease, then risks of morbidity and mortality are especially high. Our findings
in the Peoples Gas Company study are typical in this regard (Table 6). Note that for
the 128 men with hypertensive heart disease, definite or suspect, mortality from all
causes over 12 years of follow-up was almost five times as high as for the group of
208 men at lowest risk, with most of the excess deaths due to cardiovascular causes.
Note also that in the cohort of middle—aged employed men, over 90 percent white, and
free at entry of evidence of definite coronary disease, 128 of 275 hypertensives — 46. 5
percent — had evidence of hypertensive heart disease. As summarized earlier, this
proportion is even higher in the general population, white and‘black, especially the
latter. To repeat, National Health Examination Survey data indicate that in 1960-62

there were about 12, 000, 000 white American adults age 18 to ‘79 with hypertensive

22

heart disease, definite or suspect and 3, 000, 000 blacks — 15, 000, 000 altogether
(Table 4). These numbers are undoubtedly greater today — a huge pool of people with
markedly increased risk of mortality, including premature mortality (e.g. , before A
age 65).

Table 6. Hypertension, hypertensive heart disease and risk of death, cohort
of 1,465 men age 40-59 in 1958 (Peoples Gas Co. Study, 1958—70)

 

 

1958 Findings No. of 12—year Age-Adjusted Mortality Rate per 1, 000
Men All All Sudden Myocardial Stroke
Causes CVR Death Infarction

 

No Organ System
Abnormalities,
None of 3 Risk Factors 208 70 8 0 8 0

No Organ System
Abnormalities,
Hypertensive 147 156 53 22 30 12

Suspect
Hypertensive
Heart Disease 53 268 159 57 117 21

Definite
Hypertensive
Heart Disease 75 385 309 142 158 99

 

 

 

 

 

 

 

 

 

Nor is excess mortality the only problem. As data from the Social Security
Administration clearly Show, a sizable amount of disability in the labor force — at a
great economic cost to the individuals involved, to society, to government —— is attrib—
utable to hypertensive disease (Table 7). Overall, of the 330, 783 worker disability
allowances in 1968 — the year of latest record — 24 percent were due to diseases of
the circulatory system, with arteriosclerotic heart disease at the top of the list for
each of the four major sex-race groups. True, hypertensive heart disease p£r_S_e
appears among the top disability causes for blacks only, and not for whites. But these
statistics reflect the impact of hypertensive disease in only a partial, incomplete way.
Thus, the hypertensive given a disability allowance because of a severe heart attack is
not counted under the hypertensive heart category, but under the arteriosclerotic heart
category. And — conservatively — at least one-third of the coronary cases have hyper-

tension as major contributing cause of their disabling illness, and this is also true for

23

an even higher percent of persons disabled by stroke. Overall, therefore, hypertensive
disease and its complications ranks at the top of the list as a producer of disability for
all of the major sex—race groups in the labor force —— taking a disproportionate toll
among blacks, as expected, in view of their high prevalence rates for hypertensive

disease in general and hypertensive heart disease in particular. 1

Table 7. Social Security Disability Allowances, 1968,
leading causes by race and sex

 

 

White Male Black Male Other Male
All Causes 212, 061 All Causes 31, 663 All Causes 2, 718
Diseases ofthe Circulatory System 53,486 Diseases of the Circulatory alstem 7,891 Diseases of the Circulatory System 459
Arteriosclerotic Heart 38, 073 Arteriosclerotic Heart 3,255 Arteriosclcrotic Heart 271
Emphysema 13, 588 Schizophrenic Disorders 2, 535 Schizophrenic Disorders 255
Schizophrenic Disorders 12,292 Hypertensive Heart 2, 088 Osteo—Arthritis 138
Osteo-Arthritis 7,261 Pulmonary Tuberculosis 2,002 Pulmonary Tuberculosis 128
Displ. Intervertebral Disc 6,854 Cerebral Hemorrhage 1,566 Displ. Intervertebral Disc. 110
Cerebral Hemorrhage 5. 976 Osteo-Arthritis 1, 182 Diabetes Mellitus 93
White Female Black Female Other Female
All Causes 71,472 All Causes 12,291 All Causes 578
Diseases of the Circulatory System 15,001 Diseases of the Circulatory System 3,989 Diseases of the Circulatory System 80
Arteriosclerotic Heart 8.368 Arteriosclerotic Heart 1,472 Schizophrenic Disorders 41
Schizophrenic Disorders 4, 591 Hypertensive Heart 1, 358 Osteo—Arthritis 39
Osteo-Arthritls 3,815 Schizophrenic Disorders 810 Arteriosclerotic Heart 34
Rheumatoid Arthritis 3,420 Osteo-Arthrltis 688 Cerebral Hemorrhage 27
Malignant Breast Neoplasm 2, 340 Diabetes Mellitus 646 Diabetes Mellitus 25
Displ. Intervertebral Disc. 1, 971 Rheumatoid Arthritis 422 Paralysis Agitans 24

 

 

Finally, to round out this account of the impact of hypertensive disease on
health, the overall vital statistics data on mortality from hypertensive disease merit
citation (Figure 6). In brief, the patterns of mortality parallel those for prevalence,
as shown in the National Health Examination Survey data. For all four major sex—race
groups, mortality rates rise with age. At all ages (this is true up to age 85) the rates
for non—whites, i.e. , blacks, are much higher than for whites — for males age 25—44,
14.8 vs. 1.0; for females of this age, 12.3 vs. 0.8, rates 15 times as high. At ages
45-64, the rates for blacks are 6— and 7—times as high as for whites, for men and
women respectively. Mortality rates for cerebrovascular disease’show very similar
patterns, reflecting the fact that hypertension is the single most important risk factor

for strokes, both atherothrombotic (occlusive) and hemorrhagic.

24

200 A9065&Over

 

167.0

161.6

150

 

 

100

50

 

 

White White Non- Non- White White Non- Non- White White Non- Non-
Male Female White White Male Female White White Male Female White White
Male Female Male Female Male Female

Source: National Center for Health Statistics. vs. Public Health Service. DHEW

Figure 6. Hypertensive disease mortality rates by age, sex and race,
United States: 1969 (per 100, 000 population)

While these statistics give a qualitatively valid insight into the impact of hyper—
tensive disease on mortality, they are quantitatively false and misleading, i.e. , they
underestimate badly -— for reasons already mentioned in discussing the disability
statistics . This is, for a great many people with high blood pressure who die from
cardiovascular causes — as a result, at least in part, of their hypertensive disease —
the cause of death coding procedures result in their being listed under an arterioscle-
rotic heart disease, or a cerebrovascular disease category, and not under a hyperten—
sive disease category. The coronary patient who dies of a myocardial infarct, even if
”previous hypertension" is written on the death certificate, is coded as a coronary
death, and the same for a person who dies of cerebral hemorrhage or cerebral throm—
bosis, who is known to be a hypertensive. Even if the doctor writes "hypertension" as
a second cause on the death certificate — and often he does not -— the coding is to the
specified entity, so the death rate data markedly underestimate the hypertensive com—

ponent. As already noted, hypertension is present as a key contributing cause for at

25

least a third of premature heart attack deaths, and an even higher proportion of pre-

mature stroke deaths .

The data in Figure 6 are for 1969, the year of latest record. Statistics are also
available by age—sex—race for the trend of mortality rates for hypertensive disease for
the period 1940 to 1960 (Table 8 and Figure 7). The trend for white men and women
was steadily downward throughout this period, with a steeper rate of decline beginning
early in the 19508. Maximum decreases were for the 35 to 44 age group, 68 and 84
percent for white men and white women respectively. At all ages up to 65, the declines
in rate were considerably greater for women than for men. Comparison of the rates
for 1969, as presented in Figure 6, makes clear that this downward trend continued

during the 1960s.

Table 8. Percentage decrease in death rates for hypertensive disease,
1940 to 1960, by age, color and sex: United States (ICD
Codes 440-447, 7th Revision)

 

 

Ago White Nonwhite
Male Female Male Female
All ages, age-adjusted 59. 7 62. 8 37. 9 40. 6
25-34 67.7 81.2 33.3 48.3
35-44 68.3 83 9 34.5 55.2
45-54 65.3 75.9 45.7 53.3
55-64 61.8 69.4 35.0 37.4
65-74 60.7 63.4 32.7 33.8
75-84 57.4 56.3 44.5 27.5
85 8: Over 49.6 45.3 30.2 25. 1

 

 

 

 

The long—term decline in hypertensive disease mortality rates for whites had
only a limited counterpart for nonwhites, i.e. , for blacks. As can be seen in Figure 7,
their rates in 1940 were grossly higher than those for whites, ranging from-about seven
times as high at ages 25 to 34 to three times as high at age 55 to 64. With this mark-
edly poorer relative position of nonwhites at the onset in 1940, declines in rates were
slight or nil for the decade 1940 to 1950, in conspicuous contrast to the marked de—

creases for whites. For the decade 1950 to 1960, rates for nonwhites fell substantially,

26

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but at all ages up to 85 the declines were relatively not as great as those for whites,

although the absolute decreases were much larger at each age.

As a result of these trends, the relative position of nonwhites vis-a—vis whites
worsened conspicuously from 1940 to 1960. For the age groups 25 to 64, the ratio of
nonwhite—to-white rates, in the range of 3.0 to 7. 5 in 1940, virtually doubled or
trebled by 1960, so that the range became 5.0 to 20. 7 (Table 9).

Table 9. Color ratios (NW/W) of death rates for hypertensive disease,

by sex and age: United States, 1940, 1950 and 1960 (ICD
Codes 440-447, 7th Revision)

 

 

 

Age Male Female

1960 1950 1940 1960 1950 '1940
All ages, age—adjusted 3.6 2.8 2.3 3.6 2.9 2.2
25—34 12.2 8.4 5.9 20.7 10.8 7.5
35—44 13.7 7.7 6.6 18.2 10.0 6.6
45-54 7.5 5.3 4.8 10.0 6.7 5.2
55—64 5.0 3.7 3.0 6.7 4.5 3.3
65—74 3.3 2.5 1.9 3.2 2.5 1.7
75—84 1.7 1.5 1.3 1.7 1.2 1.0
85 & Over 1.4 1.2 1.0 1.0 1.0 0.7

 

 

 

 

Nonwhite females fared worse than nonwhite males in this regard, even though
their mortality rates decreased more. The highest ratio of nonwhite to white rates in
1960, 20. 7, was recorded for females age 25 to 34. The nonwhite to white ratios for

1969 were similar to those for 1960, as is evident from Figure 6.

Considerable evidence is available indicating that the observed decline in mor—
tality rates for hypertensive disease was real. Its causes — and the reasons for the
lesser downward trend for males than for females, and for nonwhites than for whites —
remain obscure, not unexpectedly, since most persons (90% or more) with elevated
blood pressure in the United States have primary (essential) hypertension, i.e. , hyper—
tension of unknown etiology. In the absence of knowledge of causation, explanations for

the downward trend are speculative and hypothetical.

28

Introduction of effective pharmacologic agents for the lowering of blood pressure
has been implicated as a possible factor responsible for the decline. However, these
drugs cannot account for the sizable 1940 to 1950 downward trend exhibited by white
males and white females, since modern antihypertensive medication dates from 1950.
It is more likely that a secular trend has occurred, largely independent of the effects
of the new antihypertensive drugs. This hypothesis is supported by the findings of
recent population surveys (see below) showing that a large proportion of persons with
hypertension are undetected and undiagnosed, that a large proportion of persons with
known hypertension are not on any treatment, and that a large proportion of known
hypertensives under treatment continue to have elevated blood pressures, so that only
a small minority of persons with hypertension are actually receiving effective long—
term therapy. Therefore it is a moot question whether the limited application of
modern treatment is sufficient in scope and impact to account even partially for the

observed downward trend in hypertensive disease mortality rates since 1950.

Correlates of hypertensive disease:

Even though most persons with elevated blood pressure have hypertension of
unknown cause, some information is available on factors related to its occurrence, in
addition to the age—sex-race patterns. It is worthwhile briefly citing particularly those
that have practical significance, in terms of the national effort to enhance public under-

standing and to control the disease.

First of all, risk of developing hypertension is related to family history (Figure
8). Those with a family history of this disease are more likely to be hypertensive than
those without. The comparative prevalence rates particularly for frankly elevated
blood pressure, diastolic 100 or greater, for populations stratified by family history —
negative or positive —— yield clear evidence of a familial tendency. This has been
shown over and over again. If both parents are involved, the risks are especially

great.

29

PREVALENCE
RATE PER LOGO MEN

   
  

     

500—
$33 FAMILY maTORY NEWIVE
429 429 1,194 MEN
400— 7/; FAMILY HISTORY Posrnvs
250 MEN
300—
200—
IOO—
58 47
7 l7 7/
o % w/fl
<70 70-79 80-89 90 MO OR)

   

Figure 8. Family history and diastolic blood pressure distribution,
Peoples Gas Company study, men age 40—59, 1958
prevalence data
This is not only potentially meaningful in terms of the unsolved problem of
possible mechanisms; it is also important in terms of ability to find hypertensive
persons or hypertension-prone persons early in life and do something for them. If
family history is associated with increase in risk, obviously one should target people
positive in this regard — in mass public health work, in practicing physicians' offices,
in efforts by health departments, schools, factories, insurance companies, the mili-
tary. Once such persons are detected, advice should be given them on possible pro—
phylactic approaches (especially safe nutritional-hygienic ones), and they should be

seen regularly by their sources of medical care.

There also is no doubt that ”spikes" of blood pressure early in life are prog-
nostically significant (Figure 9). These are data from chart records on employees of
the Peoples Gas Company in Chicago, a single blood pressure value for each man,

from his pre—employment physical examination —- when he first began to work there

30

as a youth or young adult, for men who then remained with the company 20 years or

longer.

relate to risk of elevation in middle age (20—plus years later),

of hypertensive- heart disease ? Clearly, those who

nosis of hypertension clinically,

This set of data deals with the question: How does such a young adult reading

to risk of having a diag-

"spiked" in youth are higher on every one of those criteria.

392 3-: FIRST DIASTOLIC

278 m FIRsT DIASTOLIC

‘ 33 fl FIRST DIASTOLIC

40° ————‘gg—o 6| ms: FIRST DIASTOLIC

PRESSURE < so mm Hg
Pnessuer: so -84 mm Hg
PRESSURE 85 '89 mm Hg
PRESSIARE 90 AND~> mm Hg

360

 

 

 

 

 

PREVALENCE RATE PER LOOO MEN

 

 

AMIDDLE AGE MIDDLE AGE
DIASTOLIC PRESSURE DIASTOLIC Passsuna
90 OR > 95 OR >

l
O O
.0

   
  
   
  
  

 

v

0
.0

.0

v v
.0

.0

'o'o'o'o'o
o o 0.0..

O
.0

O

 
  
 

   

  

50.... 5. .
5.0.9' .o a

335:1 .. . 3:. t - ° .
DIAGNO$|5 OF DIAGNOSIS OF HYPERTENSIVE

HYPERTENSION IN HEART DISEASE IN
MIDDLE AGE MIDDLE AGE

Figure 9. Young adult first blood pressure and development in middle age of
hypertensive disease — 20 year follow—up data on 764 men age 40-

59 (Chicago utility company study, 1958—1959)

Similar data are available from the Home Office of the Metropolitan Life Insur-

ance Company, where t

he labor force has been followed for years, and Ralph Paffen—

barger‘s data on college entrants have like implications: Teen-agers and young adults

who "spike" — in high school or college, pre—employment or Armed Forces physicals —

are not people to be ignored, in terms of the

disease .

31

significance of such "spikes" for future

Obviously, not every "spiker" becomes a frank hypertensive, so one should
evaluate judiciously. The essential point is that risk is increased, and therefore such
people must be kept under surveillance, and must be given to understand why, must be
advised nutritionally and hygienically to minimize risk insofar as possible now, and if
and when necessary put on modern pharmacologic therapy as soon as possible should

the need arise therefor.

To my knowledge, at present there are no mechanisms for the use of Armed
Forces examination data, school examination data, factory examination data, insurance

examination data, for such preventive medicine purposes.

That kind of problem — and the matters of public education, professional educa-
tion, development of such new services — need concerted long—term attention. Hope—

fully, that will be one result of this National Conference.

Figure 10 illustrates another simple fact about hypertension — intriguingly
simple, but in terms of mechanism a mystery: The relationship between relative
weight and risk of hypertension. That is, fat people get more high blood pressure
than people who are not obese. This has been shown in a hundred and one ways, with
a hundred and one sets of data. This — and Figure 11 — are just two of many examples
that might be presented here on this question. In Figure 10, from our Peoples Gas
Company study, relative weight is based on the Framingham standard. The three
groups really represent not obese or only slightly obese, "moderately" obese, and
markedly obese. Illustrated are the prevalence of hypertension per thousand at first
examination, and then the subsequent development over the next four years of new
hypertension; also, the prevalence of hypertensive heart disease at first examination,

and the incidence of new hypertensive heart disease over the next four years.

Figure 11 presents data from a more sophisticated analysis, in one respect,
i.e. , not only relative weight at one time (in this case, in young adulthood), but also
weight gain over the next 20—plus years — slight, moderate or marked. The higher
the relative weight initially, the greater the tendency to elevated blood pressure in

middle age. And — both for those lean in youth, and overweight in youth — the greater

32

the gain in weight from young adulthood to middle age, the greater the tendency to high

blood pressure:

  

PREVALENCI 0F
HYPBRTEW

INCIDENCE OF WW

2|4

         

mm OF W
HEART DISEASE
”7
HOME OF HYPERTENSIVE
HEART DISEASE

      

9 'l'1'23

 
     

m‘l

 

 

 

 

43 59 ,
.‘ . l . . - .
RELATIVE WEIGHT RELATIVE WEIGHT RELATIVE WEIGHT RELATIVE WEIGHT
ALL uuoee IOO uaAuo ALL woes: I00 “3 AND ALL UNDER I00 us AND ALL UNDER I00 "3M0
IOO To “2 OVER loo 0 M2. OVER I00 To "2 OVER loo TO “2 OVER
756 335 256 I63 594 292 I99 I03 756 335 7.58 I63 705 322 259 I44

 

 

 

 

 

 

Figure 10. Weight and hypertension, hypertensive heart disease —
756 men aged 50—59, January 1, 1954 - December 21,
1957

Every analysis of this relationship has yielded the same sort of data in many

parts of the world.

There are also data to show that if fat people reduce, their blood pressures go
down — mechanism unknown. There are some data in a recent issue of the American

Journal of Clinical Nutrition suggesting that- when fat people reduce their salt balance

 

changes, i.e. , they lose body salt (so-called occult edema), and it is the salt balance
that is involved in the relationship between obesity and hypertension. But that is not

supported by much data, and it certainly needs more documentation and further work.

33

 

 

500
500 —-- mu, 7 — ,
3691* WEIGHT SLOPE =NEGAT|VE To + 0-4
m WEIGHT SLOPE: 0.5 To L4
400 m WEIGHT SLOPE: I.5 OR >
300

 

262
253

 

 

200

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  

 

 

 

 

 

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

       

 

 

 

 

 

 

 

PREVALENCE RM' E PER LOGO MEN

I78
I00 - $7,
FIRST WEIGHT/ FIRST WEIGHT/ FEs—T WEIGHT/ FIRST WEIGHT/
DESIRABLE WEIGHT DE5IRABLE WEIGHT DESIRABLE WEIGHT DESIRABLE WEIGHT
< |.05 LOB-H4 < LOS l.05—i.l4
AGE 50 DIASTOLIC PRESSMRE 90 OR > AGE 50 DIASTOLIC PRESSURE 95 OR 7

Figure 11. Young adult first weight, 20—year weight slope, and development
of hypertensive disease in middle age — 20—year follow—up data
on 746 men age 40—59 (Chicago utility company study, 1958-59)

Be that as it may, there is a clear relation between obesity and hypertension,
and it seems reasonable to suggest — particularly for such high—risk people as those
with a positive family history, those "spiking" in youth — that one possibly helpful
hygienic measure is to avoid obesity, or correct it if already present, and use salt in
moderation, another possibility, although the jigsaw puzzle about dietary salt and
hypertension is missing so many pieces that medical research cannot as yet make out

the picture among the few pieces delineated.

Another hygienic measure, of course, flows from the fact that cigarette smok-
ing adds to the risk of the hypertensive (of. Figures 4 and 5 above). The hypertensive
who smokes is at much greater risk than the one who does not. Therefore/1t is wise
to advise people with a positive family history and/or "spiking" in youth — as well as

those with established hypertension — that they would be better off not to smoke

cigarettes .

34

Similarly, such people should be advised about the added risks associated with
hypercholesterolemia, and the nutritional prevention and correction of this trait (chiefly
by control of dietary saturated fat, cholesterol and calorie intake). In all likelihood,
hyperglycemia also adds to risk for the hypertensive individual — yet another reason
to stress prevention and correction of obesity, since fat people are more prone to

carbohydrate intolerance.

Effectiveness of antihypertens ive medication:

One of the major achievements of the past 20 years is the development of drugs
for the treatment of hypertension, and the demonstration of their optimal usage (often,

in combination) and their efficacy in preventing morbidity.

Many of my generation painfully remember the situation before 1950, when in
desperation we gave hypertensive people doses of barbiturates that made them somno—
lent throughout the day, yet their blood pressures remained high. We have seen the
development of several types of antihypertensive drugs, and the painstaking research —
under the leadership of people like Dr. Edward Freis — to elucidate the maximum
benefit to risk ratios with judicious combinations of these drugs that — given singly in
large amounts — are very troublesome in terms of side and toxic effects (e.g. , hydral-
I azine, which in large doses often produces complications like lupus; reserpine, which
in large doses often produces complications like depression and suicidal tendencies).
Thanks to such research, it is now possible to prescribe proper combinations of anti—
hypertensive drugs with lower dosages of each, and thereby achieve a favorable ratio

of benefit to risk.

That kind of research is viewed by some as piddling, mediocre, not basic,
second rate, boring, lowbrow and some people look down their nose at it as very
journeyman research. But without that kind of exquisitely neat research, we would

be in no position to talk about the large—scale control of this disease.

The kind of therapeutic effect one can get on the distribution of hypertensive

pressures is illustrated in Figures 12 and 13, from the Veterans Administration

35

Cooperative Study. As is evident, compared to baseline levels, as many men were
higher as lower when given placebo, i.e. , no reduction in pressure occurred. In fact,
there was a tendency for the blood pressure to rise on placebo, even though patients

were withdrawn if they rose too much.

 

 

I I I I I I I [ ' ' ' ' 1 ' ‘
50 7, 1

 

 

 

 

 

 

 

 

 

 

   

 

so _ PLACan ' Pucmo
0— _ m ...
ao- _ an ~ _
DECREASE INCREASE menus: INCRUSE
E .. _
m
s a
of ~ ’3 -
8 a.
5 25
3 E J
:‘E ‘ 2;: ’°” “
2!!
“- ACTIVE DRUGS ' ‘°' Acnvt onucs -
30 - 30- _
zo[ - zo~ _
IO- - )o— _
0 v 0 v
-76 -w —u -za >52 0 «2 423 '76 '60 44 ~23 -|Z o «2 .23

CHANGE IN SVSFOUC IlOOD PRESSURE - mm M; CHANGE IN DIASYOUC 81000 PRESSURE ' mm Hg

Figure 12. Changes in systolic (left) and diastolic blood pressure (right) after four
months of treatment in 57 patients given placebos (above) and 68 patients
treated with hydrochlorothiazide plus reserpine plus hydralazine (below);
men with average diastolic pressure at entry in the range 115—129 mm.
Hg

The effect of the active combination is clear cut, an average reduction of about
30 systolic, and about 16 mm. Hg diastolic in these men with average diastolic pres—
sures at entry in the range 90 to 114 (Figure 13), and even greater average declines
for men with severe hypertension (average diastolic pressures of 115—129 mm. Hg at
entry) (Figure 12). These decreases were accomplished using the combination of

thiazide, reserpine and hydralazine.

This excellent effect on blood pressure deserves special emphasis in view of

the extensive evidence indicating that of the small proportion of hypertensives under

36

care and on medication, the majority are being inadequately treated (see below) in

terms of effects on blood pressure, compared with the ability markedly to lower and

normalize blood pressure with proper use of drug combinations .

 

O " M6805

oceans: ’5 INCREASE
I
I

o - Acnvt muss

PER CEO" Of PAIIENTS

1

 

 

 

 

    

‘6‘ ~48 '3? 'l6 0 ‘lb ‘32
CMNG! IN SVSYGJC HOOD PRESSURE-mung

‘48

PER CENT 0‘ FAHENYS

 

 

..l
X
l

MCEIO

KCREASE "CHASE

    

//////// ,,,,,

ACTIVE DRUGS

Y
.
l
I

   
     

          

 

     

48 ~32 ~l6 0 ‘16 ’32 MI

CMNGI IN’ DIASYQIC ILOOD WESSURE - mm;

Figure 13. Changes in systolic (left) and diastolic (right) blood pressure in control
group of patients given placebos and experimental group of patients
treated with hydrochlorothiazide plus reserpine plus hydralazine (active
drugs); men with average diastolic pressure at entry in the range of
90-114 mm. Hg (Veterans Administration Cooperative Study on Anti-

hypertensive Agents)

Table 10 and Figure 14 illustrate from the VA study what good therapy can do in

terms of morbidity and mortality. Two sets of end points are presented — terminating

morbid events, and all morbid events . The data in Table 10 dramatically demonstrate

the efficacy of active therapy for men with severe hypertension — one vs. twenty—one

terminating morbid events, two vs. twenty-seven total events . With this highly signifi-

cant positive result, it was ethically necessary to transfer placebo patients on to active

medication, hence the trial was properly stopped long before the originally planned

five years .

37

Table 10. Effects of treatment on morbidity and mortality in hypertension -—
male patients with diastolic blood pressures averaging 115-129
mm. Hg at entry (Veterans Administration Cooperative Study on
Antihypertensive Agents)

Number of events

. Hydrochlorothiazide +

 

 

TYPe 0f Event Placebo reserpine + hydralazine
70 men 73 men
Deaths 4 0
Class A events fl 9
Subtotal 14 0
Other treatment failures _7 _1_
Total terminating events 21 1
Class B events (nonterminating) j 1
Total 27 2

 

 

 

Average period of observation: 15. 7 months for the placebo group, 20. 7 months
of the active-drug group.

/

Of the four deaths, two were attributed to dissecting aneurysm, one to ruptured
abdominal aortic aneurysm and one was a sudden death.

Class A (terminating) morbid events: hypertensive complications as defined in
the protocol which required treatment with known active agents and permanent removal
from protocol assigned therapy, including: fundoscopic evidence of grade 3 or 4 hyper-
tensive retinopathy; doubling of blood urea nitrogen to levels above 60 mg. /dl. ; dis-
secting aortic aneurysm; cerebrovascular hemorrhage (as opposed to thrombosis); sub—
arachnoid hemorrhage; congestive heart failure persisting despite digitalis and mer-
curial diuretics; elevation of diastolic blood pressure to 140 mm. Hg or higher on three
repeated visits and average rehospitalization diastolic pressure to 130 mm. Hg or higher.

Class B (nonterminating) morbid events: as opposed to class A events, where those
which did not require permanent discontinuation of protocol treatments. Patients with
developing B events could be treated with known antihypertensive agents for as long as
six months, after which protocol treatment had to be reinstimted. Class B events in—
cluded organic complications associated with atherosclerosis, such as cerebrovascular
thrombosis (as contrasted to hemorrhage which was considered a class A event) or
myocardinal infarction. Congestive heart failure which responded to routine therapy with
digitalis or mecurials and did not require antihypertensive agents also was classified as a
B event.

38

A. TERMINATING MORBID EVENTS

     
 
 

40
Control group
E 30
8
g 20
lo
.___.____._./o-—-°—° Treated group
0 4". l l j

 

0 l ’ 2 3 4 5
Years of (hservation

8. ALL MORBID EVENTS

Control group

Percent

 

 

 

Years at mservatlon

Figure 14. Estimated cumulative incidence of morbidity over a
5—year period as calculated by life table method;
terminating morbid events (above) and all morbid
events (below); men with average diastolic blood
pressures 90-114 mm. Hg at entry (Veterans
Administration Cooperative Study on Antihyper—
tensive Agents)

For men with diastolic pressures averaging 90—114 mm. Hg at entry, the most
common range of hypertension, a significant positive result also was recorded (Figure
14). Of the 186 men randomly assigned to active treatment with the 3—drug combina—
tion, 22 developed morbid events, compared with 56 of the 194 men randomly allocated
to placebo. The risk of developing a morbid event over five years was reduced from
55 to 18 percent by treatment. Terminating morbid events occurred in only 9 patients

in the treated group, 35 in the control group. Eight deaths related to hypertension or

39

atherosclerosis occurred in the actively treated group, 19 in the control group. In
addition to the morbid events, 20 patients — all in the control group — developed per—
sistent elevation of diastolic blood pressure to 125 mm. Hg or greater. The beneficial
effect of treatment was more evident in the patients with higher initial blood pressures

than in those with lower levels at entry.

Treatment apparently was most effective in the prevention of congestive heart
failure and stroke, less effective in preventing clinical manifestations of severe coro-
nary atherosclerosis. The limited size of the study precluded a definitive assessment
of ability to prevent premature coronary heart disease (CHD) by drug treatment of
hypertension. However, the data currently available support the judgment that effec-
tive long—term therapy for hypertension may help to prevent CHD and other atheroscle—

rotic diseases .

As a result of this key research, the question of efficacy of treatment of hyper-
tension is now in a very different position than it was a few years ago, when some
people could still say, "Maybe you do harm by lowering blood pressure, possibly by
reducing coronary and cerebral perfusion and you'd better be careful. " Until this VA
controlled therapeutic trial was done, no one could be sure. Now it is possible to be
definitive about the value of therapy, at least for a much broader spectrum of hyper—
tens ives than heretofore, although more data are still needed on effect of treatment
for the mildest cases, and for women, and on the ability effectively to generalize this

experience in mass public health and medical practice.

And, as a matter of fact, one of the major current endeavors of the NHLI is
the Hypertension Detection and Follow-Up Program, in which 14 centers throughout
the country are reaching out into their communities to identify every possible hyper—
tensive who can be reached in those communities, and then are randomly assigning
them (after a work-up) into two groups, one to receive usual care through the usual
medical practice mechanisms — it is no longer appropriate ethically to randomize
hypertensive persons to a placebo group, but it is appropriate to randomize them to

the care situation they would be in absent this Program — and the other half is being

40

randomized into a special care effort. This is attempting to use new approaches, in—
cluding new approaches to manpower (M.D. plus non—M.D. health workers), to place
of administration of care (home visits, et cetera), to see how much can be done to

improve the management of hypertensive persons long—term, and what the effects are

on morbidity, disability and mortality, on a community-wide basis.

That this needs improvement is by now painfully obvious .

Diagnostic and therapeutic status of hypertensive persons in the United States:

A huge problem exists in this country in regard to inadequacy of care for hyper—
tensives. Table 11 — from a recent report of the Inter—Society Commission for Heart
Disease Resources, "Guidelines for the Detection, Diagnosis, and Management of
Hypertensive Populations" gives data from three studies in the 1960s, including the
National Health Examination Survey. Of all persons with hypertension in these com-
munity surveys, about 40 percent were unaware of their condition, about a third were
under treatment, about half of the latter — i.e. , no more than 20 percent of all hyper-

tens ives — were under control.

More recent data are available from the Chicago Heart Detection Project in
Industry — data collected on over 35, 000 employed Chicagoans from November 1967
through May 1972. Figures 15 and 16 present data on the percent of previously unde-
tected hypertensives in this screened population at ages 25-44 and 45—64 respectively.
Hypertension is defined using WHO criteria — 2160 systolic and/or 295 mm. Hg dia—
stolic. The situation is no better —— to put it conservatively — than in the early and
mid—1960s. A majority of the hypertensives unaware of their condition. And, please
note, these are gainfully employed persons — not the unemployed, not the Victims of

ghetto deprivation.
That is the first problem, a huge amount of undetected hypertension.

The second problem — exemplified by the second and third set of bars in Figures
15 and 16 — is the treatment problem. Of the screenees who already knew that they

were hypertensive, less than half — a good deal less than half, particularly in the

41

251-44 age group — were on treatment, so that overall a small minority of hypertensives

(6.0 to 27. 5% maximum, depending on age-sex—race group) were on treatment.

Table 11. Estimated reservoir of undetected and untreated individuals
With elevated blood pressure

 

 

Baldwin Co. , National Health Alameda Co. ,
Characteristics Georgia Survey Calif.
of 1962 1960 - 1962 1966
Populations Surveyed N = 3084 N = 6672 N = 2495 ,
% c elev. BP
2 160 sys.
2 95 dia. 17.5% 15.2% 13.0%
% pop. on med.
for hyp. 6.0% 6.5% 5.9%
% c elev. BP on
med. for hyp. 18. 3% 23.2% 16.9%“
Total hyp. pop.* 630 1214 420M
% unknown (41. 0%) (42. 8%)
% of total hyp.
pop. on med. 29. 7% 35. 7% 35. 7%"
% of total hyp.
"under control" 14. 0% 16. 3% 22. 6%“
% of those on
med. "under control" 47. 0% 45. 6% 63. 3%“

 

 

 

* Total hyp. pop. = those with BP 2 160 systolic, and/or 95 diastolic at time of survey plus
those on medication for hypertension with survey pressures below those levels.

** In determining proportion on medication, etc. , systolic level of 165 instead of 160 was used.

Reproduced by permission from Nemat O. Borhani, M. D.

More detailed analysis revealed that this was true for both more educated and
less educated whites (Figures 17 and 18). And it was true throughout these years 1967-
1972. Apparently publication of the two reports of the VA studies on efficacy of treat-
ment — in the Journal of the American Medical Association in 1967 and 1970 (reprinted
extensively for physicians) —— has had no impact in terms of increasing the percentage
of hypertensive persons on treatment. If anything, that percentage declined from 1967
to 1972. Throughout this period it was even lower for persons age 25-44 than for those
45—64 (Figures 17 and 18), even though elevated blood pressure early in adulthood is

especially likely to exert a harmful influence.

42

PER CENT
7L7 72.I

7O
60

was WHITE MEN
I22 BLACK MEN
2?! WHITE WOMEN
93 BLACK WOMEN

=
mm
a
E

22.3 22.5 23-7
I8 O

so
40
3O
20
a 0

I74-

      
 

9.8 I2.9
6.0

   

NOT PREVIOUSLY PREVIOUSLY DIAGNOEED PREVIOUSLY DIAGNOEED
DIAGNOSED NOT ON TREATMENT - ON TREATMENT

Figure 15. Diagnostic and therapeutic status, persons age 25-44 with
high blood pressure, November 1967 — May 1972 (Chicago
Heart Association Detection Project in Industry)

PER CENT
70-650 66-4

60

2,085 WHITE MEN
I43 BLACK MEN
I,4OI WHITE WOMEN

80 BLACK WOMEN

   

57.5

  
   
  

Elfléll

46.3

40
30

26.3 27.5

IO

 

0 NOT PREVIOUSLY PREVIOUSLY DIAGNOSED. PREVIousl-Y DIAGNNED
DIAGNO‘ED NOT ON TREATMENT ON TREATMENT

Figure 16. Diagnostic and therapeutic status, persons age 45-64 with

high blood pressure, November 1967 — May 1972 (Chicago
Heart Association Detection Project in Industry)

43

3‘
in
o

 

   

 

 

 

 

 

 

   

 

 

 

 

 

 

 

 

 

      

 

   

 

 

 

PERCENT ENT _
O" TR ”M = LATE I967AND 1968 52 E
_ 11111111) 1969 E
5° E 1970 g 4f 45
EB I971 E E ‘t'
40- in I972. g E J
30— g E ::
22 g E :2
20 E g g ::
E g E :1
IO —E g g :1
o E . . ,7 E a
A A6 E 25-44 GE. 5-6 64 AG 45- 64
l-LS MORE THAN “.5. H5. 04R LESS MOEE THAN Has.
83 38 48 I29 45 94 93 l25 m I03 155 as 37 359 79 53 as 6! I63 88
NUMBER OF KNOWN HYPERTENSNES
Figure 17. Therapeutic status of known hypertensives, by year, white
men, by educational level, November 1967 - May 1972
(Chicago Heart Association Detection Project in Industry)
LATE. I967 AND I968
PERCENT
on mamas-r 6° 55 mm l969 E 3970
59. 3:“ I97! Ell |972
50-
40.
3|
301%
E I9 '7
1° g as
a: 25-44 AGE 25 «12 A65 45-64 "AGE
14.5. OR LESS MOREo THAN H 5 HS. OR LESS MORE THfiN Hits.
5| 23 60 74 28 2| 48 ll I36 91 206 480 87 25 2| 47 I26 33

NUMBER OF KNOWN HYPERTENSIVES
Figure 18. Therapeutic status of known hypertens ives, white women,

by educational level, November 1967 — May 1972 (Chicago
Heart Association Detection Project in Industry)

44

With respect to effectiveness of therapy, for those on treatment when screened,
the findings again are cause for concern: only a half approximately of the hypertensives
on treatment had blood pressures below WHO criteria for definitely abnormal levels
(Figure 19). Again, this is true for white men and white women, both at ages 25—44
and 45-64, throughout these years, without any real evidence of improvement in the

1970s compared to the late 19605 (Figures 20 and 21).

PER CENT 57.9 5 WHITE MEN

52.0 53.9 11111111 BLACK MEN 5.3 52.2
: WHITE WOMEN
E BLACK WOMEN

58d

   
 
   

    
  
   
   

50

40 35.5
so
20
lo
0
, 25 -. 44 4s — e4
l48 [9 ’76 38 565 5| 605 46

NUMBER PREVIOUSLY DIAGNOSED AND ON CURRENT TREATMENT

Figure 19. Persons previously diagnosed and on current treatment for
hypertension, percentage with systolic BP <160 and/or
diastolic BP<95 mm. Hg, November 1967 — May 1972
(Chicago Heart Association Detection Project in Industry)

The smaller number of black screenees precluded a similar detailed analysis
for them. An abbreviated one, however, clearly indicates an essentially similar situ—
ation — less than half of the known hypertensives on treatment, and less than half of

those on treatment normalized, both in the early 1970s and the late 1960s (Figure 22).

A few studies have gone yet a step further, and inquired as to the regularity of
treatment. Clearly, therapy — to be useful in preventing "complications" —— must be
continued in effective form without interruption for years. Unfortunately, this too is

rarely the case. Table 12 presents data from our study in the Peoples Gas Company

45

PERCENT WITH
5gp < I60 AND/OR

   

        
   

 
 

 

 

 

 

    

 

 

    

 

D P<95 nun/us 79 so Ea LATE I967 AND I968
f .-,, mum I969 5 I970
- ‘ F? & I97I in I972
70 L‘
60- 55 .3
so = N 43
E " 4' t 9,- 37
40—5 ‘ ' r l‘: -.
36 ;E. ‘
20% I3
10 E "W” II
c '.!!

  

AGE 25-44 AGE 4 AGE. 45-64 AGE 4
“.5. on LESS moms THAN I-I.$. ILS. OR Less MORE THAN H.s.

I8 8 I3 23 2 22 I7 [4 2| IO SCSI 45 I3835 3| 49 28 66 42
NUMBER OF KNOWN HYPERTENSIVES

Figure 20. Effectiveness of treatment of known hypertens ives on treatment,
by year, white men, by educational level, November 1967 to
May 1972 (Chicago Heart Association Detection Project in
Industry)

PERCENT WITH

 
 
 
 
  
   
  

      
 
      
       

 
 

   

  
  

 

  

 

 

 

 

 

     

 

53P<l60 AND/OR a LATE I967 AND I968 83
9913495 tum/"9 mm I969 E I970
80’ 15 Q3 197I a I972
70-63 67 67 E
6|
E: 57 57 _ 55 7
6° _E_ E so so 54 - ‘I
“‘5 4o ' 16';
40‘: __ ‘ ‘ 9‘!
E I. "1
3“ — 2" i 1
E i s!
20E :i :11
m E ' I." R-
0 II " -:

AGE. 25-44 AGE. 25-44 ' AGE 494-64 AGE 45434
14.5. OR LESS MORE THAN H9. 14.5. on LESS MORE THAN ".5.

I6 7 Is I4 6 £5 3 4 6 2 8854I052I24I I7. 5 2250m-
NUMB R OF Knows HYPERTENSIVES

Figure 21. Effectiveness of treatment of known hypertensives on treatment,
by year, white women, by educational level, November 1967
to May 1972 (Chicago Heart Association Detection Project in
Industry)

46

in Chicago of men who have been followed year after year by periodic physical exami-
nations, told that they have hypertension, and referred to their private physicians .

After about a decade of this, they were called in, interviewed about their treatment

status and examined briefly.

page EMT _
on murmur = LATE l967-I97O
60— 57 mm l97l-l972_
50*

42
4O

3O
20
IO

0

    

l
I
|
I
I
l
I
I
I
I
I
I
I
I
I
I

BLACK MEN BLACK WOMEN BLACK MEN BLACK WOMEN-

50 99 68 l69 2| 29 39 45
NUMBER OF KNOWN HVPERTENSIVES

Figure 22. Therapeutic status and effectiveness of treatment of known
hypertensives, by year, black men and women, age 25-64,
November 1967 to May 1972 (Chicago Heart Association
Detection Project in Industry)

Amazingly enough, 6. 1 percent professed not to know they were hypertensive —
hard to believe, since they were repeatedly informed for years on end, but this shows
the residual problems of communication. Only two-thirds gave a history of any treat-
ment whatever. Thirty percent were never treated, despite referrals year after year
to their doctors by the company medical department. The history of regular treatment
is low, no matter what base'is used. If the base (denominator) is those who have any

history of treatment, less than half received regular treatment.

For those on treatment at the time of the survey, only 30 percent had a reduc-
tion of blood pressure of 6 mm. Hg or more (based on the accumulated records of past
years in the medical department charts), and only 11 percent had a reduction of 16 mm.

Hg or more. (Keep in mind that a fall of 16 mm. Hg was the average reduction in the

47

Veterans Administration Study for hypertensives in the range 90—114 mm. Hg at

baseline .)

Table 12. Survey of treatment status for hypertension, Summer
1969 — middle—aged hypertensive men (Peoples Gas
Company Study)

 

 

Group Per Cent Per Cent Per Cent Per Cent
All Hypertensives 100. 0 ———————————————
Aware of Hypertension 93. 9 100. 0 ----------
History of Treatment 66. 5 70. 8 100. 0 -----
History of Regular
Treatment 29. 9 31. 8 45. 0 —————
On Treatment Now 39. 0 41. 6 58. 7 100. 0

DBP Reduced
2 6 mm Hg 11.6 12.3 17.4 29.7

DBP Reduced
2 16 mm Hg 4.3 4.5 6.4 10.9

 

 

 

 

 

 

 

Similar data are available from the study in Baldwin County (Atlanta).

A simple set of figures — rough but reasonable approximations of the situation
as revealed by the several population surveys — is very useful for boiling the problem
down to its somber, harsh realities and pinpointing the challenge to our health educa—
tion and medical care delivery system: 1/2 x 1/2 x 1/2. One half the hypertensives
undetected. One half the known hypertens ives untreated. One half the treated hyper—
tensives inadequately treated. Q.E.D.: Only one-eighth of the 20 to 25 million hyper-
tensives detected and adequately treated, based on the modest criterion of a current
lowering of blood pressure to systolic less than 160 and/or diastolic less than 95. For
an optimal blood pressure response, lower values — sustained long-term — are appro-

priate. To maximize prevention of "complications, " comprehensive care — not just

48

drugs to lower blood pressure — is necessary, e.g. , correction of cigarette smoking,
hypercholesterolemia, hyperglycemia—diabetes, obesity for the hypertensive. Conser-
vatively, then, seven—eighths of the hypertensives — seven-eighths of 20 to 25 million

persons — are being inadequately served. Quite a challenge indeed!

Why is this practice experience so unsatisfactory? Little has been done to
clarify this and it needs more work, but there are certain pieces of information avail—
able. One thing is suggested by the data of Table 13, at least for the diagnosed hyper-
tensives: It doesn't relate to frequency of visits to physicians. The majority of the
hypertensive men in the Peoples Gas Company were going to their doctors at least
quarterly, so at least to the extent that not getting medical care is involved, that is

not the whole problem.

Table 13. Frequency of visits to physicians, 64 (of 164) middle-aged
hypertensive men currently on treatment, survey of treat-
ment status, Summer 1969 (Peoples Gas Company Study)

 

 

Cumulative
Group Per Cent Per Cent

All Hypertensives

Currently on Treatment 100. 0 100. 0
At Least Monthly Visits

to M.D. 32.8 32.8
At Least Quarterly Visits

to M.D. 23.4 56.2
At Least Semi-Annual Visits

to M.D. 28.1 84.3
Annual or Less Frequent

Visits to M.D. 15.6 99.9

 

 

 

 

 

Patients often quit taking medication. In Baldwin County, patients were asked,
"Why did you stop taking medication?" As is evident from Table 14, financial consid—

erations were one, but not the main reason. They didn't realize they should continue;

49

they felt better; they took drug "when needed. " Obviously successful doctor-patient
communication on the importance of regular, sustained, long—term therapy for hyper-

tension has not yet been achieved.

Table 14. Reasons why treatment for hypertension
was discontinued (Baldwin County Hyper—
tension Survey, 1962)

 

Number giving reasons 104
Total* 110%
Financial considerations 16

Didn't realize should

 

 

continue 12
Felt better. 30
Take when needed 16
Miscellaneous 36 I

 

* Totals more than 100 because some gave more than
one reason.

And when the nature of therapy is evaluated, it is clear that the medical profes-
sion generally has not yet achieved high level awareness, by and large, as to the poten-
tial for a high benefit to risk ratio with use of combinations of medication, rather than
single drugs, and particularly use of such triple combinations as were employed so

effectively in the VA study.

For example, a minority of the patients on treatment in the Peoples Gas Com-
pany were taking effective combinations at the time of our survey in 1969.(Table 15).

Thus, there obviously is a big challenge in the area of M.D. education.
Are these problems at all rectifiable?

Figure 23 illustrates one of the few experiences on this. These are data col—
lected in the Baldwin County study. At the time of the first mass survey, in 1964, the
treatment situation was deplorable. Therefore, a special program was begun to try to

improve prescription and adherence.

50

Table 15. Treatment regimen and major drop in blood pressure,
64 hypertensive men (Peoples Gas Company, Hyper-

tension Treatment Study, 1969)

 

 

 

 

Drug Regimen No. of Men Fall in Blood
Pressure of _>_16 mm. Hg
Diastolic or 220 mm. Hg
Systolic
No. of Men Per Cent
Thiazide Only 12 20 1 2 8 10
Rauwolfia Only 8 1 12
Thiazide + Rauonfia 13 3 23
Others Only 9 35 3 9 23 26
Thiazide and/or Rauwolfia
+ Others 13 3 23
Unknown 8 0 0
All 63 11 17

 

 

 

 

 

 

A home visiting program by nurses was instituted. Good control was defined
as diastolic pressure under 95 mm. Hg. The rates went up to 86 percent on prescrip-
tion, and 80 percent under good control. The pilot program was discontinued, having
proved its efficacy! Not unexpectedly, when the firm, steady persuasion and education
of such a program stopped matters slipped sizably. Two years after the end of the

program, both treatment status and effectiveness of control had regressed.

The lesson is clear: in any medical care program for chronic disease, good,
long—term sustained therapy must be systematically assured, whether it be for hyper—
tension or other problems, e.g. , adherence to programs for cessation of cigarette

smoking, change in diet, etc.

51

ALL uvpemeusnve
VOLUNTEERS
loo °/o

75—

50-

p
m

25' I 5

ON Rx GOOD CONTROL ON Rx GOOD CONTROL ON Rx GOOD CONTROL

 

BEFORE DURING 2YR$ AFTER END
PROGRAM PROG RAM OF PROGRAM
l964 l966 1968

Figure 23. Effects of home follow—up program on 88 hypertensive volunteers,
Georgia — percent on treatment and good control, before, during
and 2 years after program

Programmatic proposals for the control of hypertension:

 

The entire history of modern public health teaches a fundamental lesson about
the control of mass disease problems — a lesson highly relevant for this one: Mass
public health problems require mass public health approaches to their solution, i.e. ,
community — as distinct from individual — methods. The simple doctor—patient rela—

tionship is not by itself capable of doing the job.

This fundamental point was made almost a decade ago, in 1964, at the Second
National Conference on Cardiovascular Diseases, jointly — and appropriately — co—
sponsored by the national voluntary and official agencies, the American Heart Associa-
tion, the Heart Disease Control Program of the Public Health Service, and the National
Heart Institute. Here are the recommendations in its Community Service Summary

Report:

52

Hypertension as defined by the World Health Organization is a
problem which is amenable to community efforts in detection, diagnosis
and management.

Casefinding is essential but of little value unless it is followed by
referral to sources of medical care and systematic follow—up.

Physicians should be shown the importance of early and adequate
treatment of mild benign hypertension. All those identified as hyper—
tens ive should have further diagnostic work—up to find curable forms of

hypertens ion .

In the 1970s, the Inter—Society Commission for Heart Disease Resources, in its
Reports, "The Primary Prevention of the Atherosclerotic Diseases" and "Guidelines
for the Detection, Diagnosis, and Management of Hypertensive Populations, " reaffirmed
this basic concept and elaborated specific approaches for its implementation and fulfill-
ment. While these reports merit complete reading and detailed study, quotation here

of particularly salient portions is useful.

From the first of these two Reports:

Recommendations for Primary Prevention

The Commission recommends the immediate and concurrent
implementation of the following recommendations for the primary pre—
vention of the atherosclerotic diseases:

National Policy Commitment to Strategy of Primary Prevention

A. The Commission recommends that a strategy of primary preven—
tion of premature atherosclerotic diseases be adopted as long—term
national policy for the United States and to implement this strategy that
adequate resources of money and manpower be committed to accom—

plish:

. . . Changes in diet to prevent or control hyperlipidemia,
obesity, hypertension and diabetes

. Elimination of cigarette smoking

. Pharmacologic control of elevated blood pressure. . . .

53

Detection and Control of Hypertension

E . The Commission recommends a major national effort to detect
and control hypertension. Recent studies have shown that the preva-
lence of elevated blood pressure is generally high in the United States,
especially in the black population. Many hypertens ives have not been
identified; many others known to have the disease are not receiving
adequate therapy. Programs are urgently needed to identify hyperten—
sives in the community and assure their subsequent treatment. The
recently published positive results from the Veterans Administration
field trial of drug therapy for so-called "mild" hypertension underscore
the potential significance of such programs.

Community Programs

F. The Commission recommends that community programs be de—
veloped and expanded for the detection and treatment of persons of all
ages who are very susceptible to premature atherosclerotic diseases

due to combinations of the major risk factors.

This recommendation is premised on extensive experience dem-
onstrating that effective community programs for prevention of disease
generally combine measures addressed to the entire population with
concerted efforts for the detection and care of high risk individuals .
All available evidence indicates that this well—established principle
applies to the prevention of the atherosclerotic diseases.

On the basis of recent experience, detection programs are likely
to identify a very large proportion of the population — e.g. , about 20 or
30 percent of middle—aged adults — as being at unusually high risk.

For such individuals, community services should be provided to assist
their physicians in long-term management. Such programs will require
the training and use of large numbers of allied health personnel, as
well as physicians .

And from the second of these two reports, this latter one presenting splendid
10—page—long concrete and detailed, "Guidelines for the Detection, Diagnosis and Man—
agement of Hypertensive Populations":

Community control of hypertension represents a great challenge
to American medicine. The large numbers affected and the relatively
small percentage of hypertensive patients under adequate control sug—

gest the magnitude of the opportunity. The scope of the problem is re—
flected by the lack of adequate diagnostic and therapeutic facilities to

54

manage the case load and the relatively high prevalence of hypertension
in economically underprivileged areas including overcrowded urban
centers . Solutions to the problems of detection and maintenance of
effective treatment for populations of hypertensives will require long-
term planning and the allocation of sufficient funds for the training of
needed manpower, facilities and other related costs. In the long run it
should be less expensive to control hypertension than to care for those
who become disabled and economically unproductive as a consequence
of the disease. . . . If a community hypertension control program is to
be successful, it must . . . develop techniques for continued physician
and patient education, effective longitudinal patient follow-up and care
and means to provide free or low-cost drugs. . . .

Case detection for hypertension can easily be incorporated into
most multiphasic screening programs . Community planners should
understand that control of hypertension will yield major health and
economic benefits for large numbers in our society.

II. Early Detection

Hypertension is usually an asymptomatic disease in its early
phases but serious complications may occur frequently without warning.
It is unrealistic, therefore, to rely on symptoms alone to prompt pa—
tients to seek medical care. There are essentially two approaches to
finding hypertensives in the population: incidental screening and organ—
ized community screening. For effective hypertension control, most
communities must supplement incidental screening with organized
community programs for recording blood pressure in asymptomatic
persons . . . .

Population to be Screened

The population between 15 and 65 years of age should be routinely
screened. To reach this goal, however, most communities will have
to plan long—range programs and establish priorities for screening.

The black population, irrespective of economic status, has a
very high prevalence of hypertension and screening correspondingly
produces a high yield of undetected, untreated or inadequately treated
individuals .

Undetected and untreated hypertension is also quite common in
any low income group -— irrespective of geography or ethnic mix. Be-
cause of the high prevalence of all diseases and social ills in such dis-
advantaged areas, it is especially important that hypertension screen-
ing be incorporated as a part of comprehensive health maintenance

55

programs for these populations. Unless adequate diagnostic and treat-
ment resources are provided for all disorders found, screening of any
kind will serve only as another source of mounting frustration.

Finally, the prognosis of hypertension in the age group 15—30
years is particularly poor and these individuals should be identified
and treated as early as possible. . . .

Method of Follow—Up

It is extremely important that better use be made of the informa-
tion regarding patients with hypertension identified by various types of
incidental screening programs . This effort requires more comprehen—
sive professional education concerning the necessity for following and
treating these patients, and more effective patient education regarding
the importance of early diagnosis and adequate long-term management.
Various methods to assure maximum follow—up of those patients identi—
fied through incidental screening should be developed and evaluated in
each community.

Hypertensives identified in community screening programs
should be referred. Since there is a tendency for many patients to
ignore screening findings, repeated follow—up is usually required, and
intensive educational programs for patients and their families may be
necessary to assure cooperation.

Professional and Public Education

To be successful, any community program for the early recogni-
tion of hypertension must be accompanied by intensive professional and
public education. Professionals should be alerted to the significance of
hypertension as a serious disease and the importance of long-term
follow—up for the labile hypertensive. They should be made aware of
the recent evidence that therapy both decreases the rate of damage to
the vascular system and prevents complications and they should know
that even patients with moderate hypertension may benefit from effec—
tive treatment. It should be emphasized that hypertension is not a cur—
able disease in most instances and must be evaluated periodically for
the duration of the patient's life. Hypertension carries a familial rela-
tionship and its presence in one member of the family should alert phy-
sicians to screen relatives for unsuspected or untreated disease. If
teenagers are screened, special instructions should be sent to physi—
cians outlining the importance of borderline blood pressure levels and
guidelines for therapy in this population. If the screening program is

56

to succeed, it is essential that the professional education program pre—
cede that of the public. However, an intensive public information pro-
gram will be necessary before and during the community screening. . . .

IV. Resources for Therapy

Since two-thirds of the patients identified as hypertensive are
either not aware of their disease or have discontinued therapy, screen-
ing programs may triple the case load requiring treatment. Long—
range local planning will be required to manage effectively this patient
population without seriously overloading existing medical facilities.

The stratified system of care suggested here represents one
approach to the problem (Figure 2)*. Stratified care means that a
community's medical facilities are organized into a layered system in
which each plays a separate but essential role. One level is composed
of various facilities for ambulatory care including physicians' offices,
hospital outpatient clinics and neighborhood health centers. These are
supplemented by specialized neighborhood hypertension units . At an-
other level is a regional reference center for hypertension. Between
are specialty hypertension services located in community hospitals of
various sizes which provide both inpatient and outpatient facilities for
management problems that cannot be handled effectively by the primary
physician at the neighborhood level. Other community hospitals are
incorporated into the system as described below.

Organizing medical resources into a stratified system for hyper-
tension control should help reduce duplication and overlap of function
among facilities, provide additional supportive services for primary
physicians and, thereby, enhance access to more 00mprehensive care
for larger segments of the hypertensive population. . . .

Conclusion
Existing medical services often fail to provide satisfactory long—
term care for patients with hypertension as evidenced by the large num-

ber who either leave therapy or receive inadequate treatment. In par-
ticular, economically underprivileged urban residents require more

* Figure 24 of this paper is Figure 2 of the quoted Inter—Society Commission Report.

57

 

 

 

 

individualized management than can presently be provided in the deper—
sonalized and overcrowded outpatient clinics of many large municipal
and community hospitals . The development and evaluation of new and
more effective techniques for delivering long-term care to all hyper-
tensive patients is urgently needed. The proposed stratified system
for organizing community resources for hypertension control, incorpo—
rating the concept of the neighborhood hypertension unit, represents
one possible solution. Since this approach is relatively new, initial
testing in the form of pilot studies will be necessary to evaluate effec-
tiveness and feasibility and to make necessary modifications to meet
local needs. Implementation of the system and the neighborhood unit
concept and tailoring it to meet local needs necessarily involves a long-
range organized approach to community and regional planning. . . .

 

 

 

 

 

 

 

 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Community Primary Supporting
Stfrt'enlttfl Physician Scr‘viccs
Type 1‘ Type II Type III
Private
'4 Practice Hospital with
l-lypertension Specialty
p
J __ E Referral '4 Service ‘A
. ‘L z D
5.: Hospital 2 : lgohlind A \
3—in‘unh:latory Care MM 3 E " . \ Regional
:2 irograms ‘ E“ E Primary Reference
1} a l’hysrcran Center
. ‘ ,3: and/or -
J“ Group , " Neighbor— v /
Practice 1" l hood Unit ‘\ ’9,
(including Hospital without V”
l "HMO'5") Hypertension Specialty
' Service

 

 

 

 

 

Neighborhood
Health Centers

 

 

 

* The Neighborhood Hypertension Unit is a community scrvicc which assists the primary
physician with long term follow-up and management of his hypertensive patients. Since many
patients with hypertension have combinations of cardiovasrulor risk factors, it is prcfcrahlo
that this service be incorporated as part of a comprehensive risk factor intervention program,
e.g._. diet and cigarette smoking control. exercise programs, diabetes control. ancnding on
local newls, tlwsc services can stand alone in their own facility or, what is more likely, llle'll
can be incorporated into other facilities and programs such as camprcheuicc neighborhood
health centers, hospital ambulatory care programs, group practicrs (including [1510's 1. health
department programs, community health educations centers, ctc.

Figure 24. A stratified organization of medical resources for hypertension control

58

These two Inter-Society Commission Reports were published in 1970 and 1971
respectively. Viewed optimistically, only the barest beginning has been made in the
implementation. of their recommendations —— be the basis of judgment the matter of an
overall commitment to a strategic policy of prevention and control, or the commitment

of money, manpower, resources.

Essentially, it is still unclear whether these Reports and their recommenda-
tions will indeed become effective Guidelines of a determined national effort, or —
like the 1964 Report of the Second National Conference on Cardiovascular Diseases —

esoteric tomes doomed to gather dust in the archives and libraries.

It is therefore necessary to go beyond the biomedical and health aspects of the
hypertension problem, the focus of this presentation up to this point, and discuss the
social, medical and financial aspects, although humanistic considerations — and the
classical mission of medicine, to give mankind added years of better life — must
continue to be regarded as the overriding determinant of public policy and national

priority.

The financial and social soundness of the effort to control hypertension:

The foregoing quotation from the ICHD Report stated: ”In the long run it should
be less expensive to control hypertension than to care for those who become disabled
and economically unproductive as a consequence of the disease. " If this is valid, the
effort to control hypertension —— like other preventive medicine undertakings to control
mass disease (e.g., cholera, smallpox, typhoid, pellag'ra, scurvy, rickets) — should

more than pay for itself financially.

Although only limited facts are available, there are data permitting a specific
assessment of this relevant question. Thus, the President's Commission on Heart
Disease, Cancer and Stroke in its 1964 Report made estimates of the economic costs
of heart disease and stroke in 1962 (Table 16). The American Heart Association has

recently published projections of costs of cardiovascular diseases for 1973 (Figure 25).

59

Table 16. Estimated economic costs of heart disease and stroke by type
of‘cost, 1962 (millions of dollars)

 

 

 

 

 

 

 

 

 

 

 

 

Total
Type of cost cardiovascular Heart Disease Stroke
diseases

Total ———————————————————————————— $31,867.4 $30, 720.4 $1,147.0
Direct costs ——————————————————————————— 3,072.2 2,627.0 445.2
Personal services and supplies —————————————— 2, 579. 7 2, 189. 5 390.2
Hospital care ————————————————————— 1,234.8 1,023.2 211.6
Nursing home care —————————————————— 299. 8 191. 1 108.7
Physicians' services ————————————————— 701.4 641.9 59.5

Drugs _________________________ 279.4 279.4 (1)
Nursing services ——————————————————— 64.3 53.9 10.4
Non-personal services ------------------ 492. 5 437. 5 55. 0

Research ——————————————————————— 117.0 117. 0 (1)

Training ——————————————————————— 19.8 19.8 (1)

Other health services ————————————————— 34. 4 34. 4 (1)
Construction ————————————————————— 190. 0 150- 1 39.9
Net cost of insurance ————————————————— 131. 3 116.2 15. 1
Indirect costs —————————————————————————— 28,795.2 28,093.4 701.8
Mortality _________________________ 25, 824.6 25, 590. 7 233. 9
1962 __________________________ 1,286.8 1,052.9 233.9

Previous years2 ——————————————————— 24,537.8 24,537.8 (1)
Morbidity ————————————————————————— 2,970.7 2, 502.7 468.0
Institutionalized ————— - -------------- 455.9 289.7 166.2
Noninstitutionalized —————————————————— 2,514.6 2,212.9 391.7

 

 

 

 

 

 

1 Breakdown not applicable; expenditures included in heart disease.

2 Estimated loss in 1962 from deaths in previous years based on survival probabilities resulting from eliminating cardiovascular
diseases (including stroke), assuming the death and disability rates for this cause were zero while the rates for all other
causes remained unchanged.

And the 1971 Report of the National Heart and Lung Institute Task Force on Arterio—
sclerosis (Volume II) gives the most detailed estimates, for 1967, including estimates
specifically of the costs of hypertension M (Tables 17 through 20). From Tables
19 and 20, it is evident that morbidity, disability and mortality from hypertensive dis—
ease M among people under age 65, in the productive years of life, is costing the
nation over one billion dollars annually in indirect costs. Since hypertension is a

major risk factor contributing significantly to causation of at least a third of premature

60

heart attacks and strokes, roughly another 3. 5 billion dollars in indirect costs of hyper-
tensive disease prior to age 65 lie concealed in these categories, summating to about
4.5 billion dollars in indirect costs. A similar calculation gives a direct cost estimate,
irrespective of age, of almost two billion dollars. It is reasonable to estimate that at
least one—quarter of this is spent for persons under age 65, i.e. , about a half billion
dollars . Therefore the total costs of hypertensive disease among persons under age

65 sum up to about five billion dollars for 1967.

 

 

 

 

 

 

 

g 20 19.58illion
E
s
15
10
7.4 Billion 7. 3 Billion
5
2.3 Billion
E 0 6 3'". 1.9 Billion
. I Ion
o z: I!
Physician HOSpital Cost of Research Lost Total
and and Medi- and Con- Wages Cost
Nursing Nursing cations structlon.
Services Home Etc.
Services

Source: American Heart Association

Figure 25. Estimated economic costs of cardiovascular diseases by
type of expenditure, United States: 1973

61

Table 17. Estimated economic costs to the nation due to morbidity
and mortality from arteriosclerotic and hypertensive
diseases, United States

 

 

 

 

 

Amount (in millions)
Total Morbidity Mortality
Diagnosis Costs*
Direct Indirect
Costs Costs
Total (Arteriosclerotic or
Hypertensive) $23, 887 $4, 291 $1, 133 $18, 463
Arteriosclerotic
Heart Disease 15, 545 2, 072 370 13, 103
StrokeM 4,605 971 235 3,399
Diseases of Arteries 1, 082 354 31 697
Hypertensive Diseases"* 2,655 894 497 1,264

 

 

 

 

 

 

 

* Present value of lifetime earnings (discounted at 6%) of persons who died of
arteriosclerotic and hypertensive diseases.

** Includes 20% not due to arteriosclerosis.

*** Does not include all arteriosclerotic disease in which hypertension was involved.

Table 18 . Estimated direct costs of morbidity from arteriosclerotic
and hypertensive diseases by type of expenditure, United

 

 

 

 

 

 

 

 

 

States
Amount (in millions)
Type of Expenditure“
Diagnosis Total Hospital Physicians' Drugs Nursing Other
Care Services Home Medical
Care Profes-
sional
Services
Total $4,291 $2. 253 $843 $599 $462 $134
Arteriosclerotic
Heart Disease 2,072 1,280 319 237 171 65
Stroke 971 577 103 57 204 30
Diseases of
Arteries 354 216 51 28 48 11
Hypertensive
Diseases 894 180 370 277 39 28

 

 

 

 

* Excludes expenditures for dentists' services, eyeglasses and appliances, prepayment and
administration, government and other health services, research and medical facilities
construction.

62

 

Table 19 . Estimated man-years lost to productivity and indirect
costs due to morbidity from arteriosclerotic and

hypertensive diseases; United States

 

Man-Years Lost

 

Indirect Costs

 

Diagnosis to Productivity“ Due to Morbidity
(in millions) (in millions)
Total 227. 5 $1, 133
Arteriosclerotic Heart Disease 63.3 370
Stroke 56.2 235
Diseases of Arteries 7.7 31
100. 3 497

Hypertensive Diseases

 

 

 

 

* Includes losses by currently employed persons and housewives.

Table 20. Estimated indirect costs of mortality* from the
arteriosclerotic and hypertensive diseases, by
broad age group; United States

 

Amount (in millions)

 

 

 

Diagnosis Total Under Age 65

Age 65 and Over
Total $18,464 $11,135 $7,329
Arteriosclerotic Heart Disease 13, 103 8,284 4,819
Stroke 3, 399 1, 760 1, 639
Diseases of Arteries 698 324 374
Hypertensive Diseases 1,264 767 497

 

 

 

 

 

* Present value of lifetime earnings (discounted at 6%) of persons who died of arteriosclerotic

and hypertensive diseases.

63

 

 

Acknowledgements

It is a pleasure to acknowledge the co-operation of the author's senior colleagues
in the long-term investigations presented here: eSpecially David M. Berkson, M.D. ,
Yolanda Hall, M.S., Howard A. Lindberg, M.D. , Louise Mojonnier, Ph.D. , James A.
Schoenberger, M.D., Richard Shekelle, Ph.D. and Rose Stamler, M.A.

It is also a pleasure to express appreciation to the many Chicago organizations
giving invaluable co-operation in the cited research efforts, particularly the Peoples
Gas Light and Coke Company, its chairman, Remick McDowell and its medical director,
Howard A. Lindberg, M.D. Acknowledgement is also gratefully extended to all those
involved in the Chicago Heart Association Detection Project in Industry: Louis deBoer,
executive director and Kay Westfall, program director; the Chicago Heart Association
Detection PrOject in Industry Staff: Pamela Bessmond, Thelma Black, Clarice Blanton,
Joan Carothers, Arlene Dungca, Mary Ann Foelker, Susan Forkos, Carol Fulgenzi,
Harold Gram, Jean Graver, Inger Hansen, Cherry Latimer, Susan Shekelle, Karen
Strentz, R.N. and Suzann Ward, R.N. Volunteer Members of the Heart Disease Detec-
tion Committee of the Chicago Heart Association and its Subcommittees: Howard Adler,
Ph.D. , Rene Arcilla, M.D. , Robert Arzoecher, Ph.D. , Richard A. Carleton, M.D.,
Angelo Cottini, Edwin Duffin, Ph.D., Morton B. Epstein, Ph.D., Robert E. Fitzgerald,
M.D., Philip Freedman, M.D., Burton J. Grossman, M.D., Mark M. Lepper, M.D.,
Robert R. J. Hilker, M.D., Robert S. Kassriel, M.D., Howard A. Lindberg, M.D.,
Clinton L. Lindo, M.D., Gerald Masek, Ph.D., Richard McNamara, Robert A. Miller,
M.D., Robert D. Mosley, Jr., M.D., Milton H. Paul, M.D., Willie Reedus, R.N.,
Raymond Restivo, Wallace Salzman, M.D. , Robert Sessions, Richard B. Shekelle,
Ph.D. , Howard H. Sky—Peck, Ph.D., Donald Singer, M.D. , Lachichida Sinha, M.D.,
Grace Smedstead, Ralph Springer, Rose Stamler, M.A. , J. Martin Stoker, M.D. ,

Carl Vogel, Ira T. Whipple, M.S., Quentin D. Young, M.D.

The author is most grateful to the principal investigators of the prospective
studies of Albany civil servants, Chicago Western Electric Company employees,
Framingham community residents, Los Angeles civil servants, and Minneapolis —St.

Paul business and professional men, and to the coordinators of the national cooperative

64

Pooling Project. It is a pleasure to acknowledge the cooperation and aid of our col—
leagues in this endeavor, Drs. Henry Blackburn, John M. Chapman, Thomas R.
Dawber, Joseph T. Doyle, Frederick H. Epstein, William B. Kannel, Ancel Keys,
Felix J. Moore, Oglesby Paul, and Henry L. Taylor.

Appreciation is also expressed to the following colleagues and publishers for
permission to cite from published works: Edward D. Freis, M.D. , Ralph S. Paffen—
barger, M.D. , Joseph A. Wilber, M.D.; the American Heart Association, American
Journal of Public Health, Journal of the American Medical Association, Minnesota

Medicine .

The author's research has been supported by the American Heart Association;
Chicago Heart Association; Illinois Regional Medical Program; and the National Heart

and Lung Institute, National Institutes of Health, United States Public Health Service.

65

10.

11.

References

Heart Disease in Adults, United States, 1960—1962. Data from the National
Health Survey, National Center for Health Statistics, Series 11, Number 6,
U. S. Department of Health, Education and Welfare, Public Health Service,

Washington, D.C. , 1964.

 

Inter—Society Commission for Heart Disease Resources.
Atherosclerosis Study Group and Epidemiology Study Group.
Primary Prevention of the Atherosclerotic Diseases.
Circulation, 42, A55, 1970.

Paffenbarger, R.S., Notkin, J., Krueger, D.E., Wolf, P.A., Thorne, M.C.,
LeBauer, E. J. and Williams, J .L.

Chronic Disease in Former College Students. II. Methods of Study and Obser—
vations on Mortality from Coronary Heart Disease.

Amer. J. Public Health E, 962, 1966.

American Heart Association.
1973 Heart Facts, American Heart Association, New York, N.Y. , 1972.

Moriyama, I.M., Krueger, D.E., and Stamler, J.
Cardiovascular Diseases in the United States, Harvard University Press,
Cambridge, Mass., 1971.

Stamler, J.
Lectures on Preventive Cardiology, Grune and Stratton, New York, N.Y. , 1967.

 

Veterans Administration Cooperative Study Group on Antihypertensive Agents.
Effects of Treatment on Morbidity in Hypertension — Results in Patients
with Diastolic Blood Pressures Averaging 115 through 129 mm Hg.
J.A.M.A.,_2% 1028, 1967.

Veterans Administration Cooperative Study Group on Antihypertens ive Agents.
Effects of Treatment on Morbidity in Hypertension. II. Results in Patients
with Diastolic Blood Pressure Averaging 90 through 114 mm Hg.

J.A.M.A., E, 1143, 1970.

Wilber, J.A. and Barrow, J.G.
Reducing Elevated Blood Pressure—Experience Found in a Community.
Minnesota Med. , _5_2, 1303, 1969.

Inter-Society Commission for Heart Disease Resources.

Hypertension Study Group.

Guidelines for the Detection, Diagnosis and Management of Hypertensive Pop-
ulations. Circulation, 42 A263, 1971.

Schoenberger, J .A., Stamler, J ., Shekelle, R.B. and Shekelle, S.
Current Status of Hypertension Control in an Industrial Population.
J.A.M.A., _2_22_, 559, 1972.

66

THE PROGNOSIS FOR HIGH BLOOD PRESSURE
Charles C. Edwards, M.D. *

I am certainly pleased to have the opportunity to take part in this conference,
because it marks a major turning point in the effort to deal with one of the most serious
health problems of our time. No one could question the need for an all-out attack on
hypertension. The evidence is overwhelming that sustained high blood pressure is
associated with increased morbidity and mortality as well as with untold suffering
related to physical and emotional stress. When reliable means of detecting hypertension,
and effective means of treating it are available — as indeed they are — then ethics,
humanitarianism, and plain common sense demand that they be used as fully and
effectively as possible.

Yet they are not being used as fully and effectively as possible. People knowl-
edgeable in this field estimate that there are as many as 23 million persons afflicted
by high blood pressure in the United States — roughly 10 percent of the total population —
but that only a fraction of that number are receiving the care they need, care that can
save them from premature death and needless suffering. I find that intolerable, because
it is unnecessary. As a physician, I applaud the launching of a concerted effort aimed
at raising the level of understanding of this disease and at bringing effective care to
countless millions of people who need it but are not getting it.

Let me say, too, that I believe Secretary Richardson, by providing the impetus
for this program, has shown not only a keen insight into a very complex problem of
health planning and health care delivery, but also a sense of compassion and dedication
to the public welfare that makes him one of the ablest and most effective men ever to
serve in the highest levels of government. I am sure I express the sentiment of this
audience in offering him our thanks and in wishing him well.

The Food and Drug Administration welcomes the chance to play a role in the
national program that is being developed here today. We welcome this opportunity

for two reasons: First, because it represents a major initiative against a major

* Commissioner, Food and Drug Administration, Washington, D.C.

67

unmet health problem; and second, because it can and will help the FDA do a more
effective job in advancing the quality of health care available to the American people.
I want to say a few words about each of these points.

I think we all recognize that there are some very difficult unanswered questions
about hypertension. A quick look at the medical literature reveals disagreement on
what constitutes true hypertension, on the reliability of routine screening techniques,
and also on the indications for treatment of the disease in the absence of other evi—
dence of serious illness. Certainly, these questions have to be answered, and that is
one of the major aspects of the national program now being planned.

There are other critically important things about hypertension, however, that
leave no room for doubt and indecision and provide no excuse for inactivity. The
most important of these is the fact that hypertension can be treated and controlled
with the use of drugs that are now available. I think it is safe to say that no other
form of chronic illness —— and certainly none of the major, life-threatening ones ——
is as susceptible as hypertension to effective, long—term control. Here is another
thing about hypertension that leaves little room for doubt: If the disease is untreated
or ineffectively treated, especially among young and middle aged persons, the con-
sequences are extremely likely to be disastrous. Clinical experience, backed up by
the results of epidemiologic studies, leaves no doubt that the human circulatory
system cannot withstand the burden of sustained high blood pressure. Ultimately it
breaks down, and when it does, a chronic impairment becomes an acute emergency.

These are not newly uncovered research findings. I am not talking about some
new revelations that have emerged from the laboratory and the clinic. On the con-
trary, the threat of hypertension has been recognized for decades, and agents that
can effectively control it have been widely available for many years. Why then is so
little being done to apply What we know how to do in the face of a problem we know
exists? Why are most of these persons apparently unaware of the fact that they need
help? I don't know the answers to those questions. No one does. But I do know that
we have to get the answers, because without them the prognosis for hypertension will
have little chance to improve.

Although I don‘t know all the factors that account for our failure to come to grips

68

with the national problem of high blood pressure, it seems clear that the biggest
stumbling block we have to cross is an all too familiar one — ignorance. Despite the
efforts of voluntary health organizations, professional societies, and Federal agencies,
the people of this country seem to be dangerously ignorant of the threat of high blood
pressure, of the need to detect flat the earliest possible time, and of the opportunities
for effective treatment. Ironically, people seem to know more about diseases that
affect far fewer people and are much less responsive to treatment than they do about a
condition that may exist in one person out of ten, and one for which the results of avail-
able treatment methods can be little short of miraculous.

Clearly, this national program has to take direct aim at the need for public edu-
cation about high blood pressure. We have to find and exploit ways of reaching people
of all age levels, all economic situations, all ethnic backgrounds, and all occupational
and home environments. We have to give them a sense of responsibility and confidence —
responsibility to find out whether they have high blood pressure, and confidence in the
knowledge that the disease can be safely and effectively controlled.

We have more than a problem of public education to contend with, however. We
also have to give very serious thought to the need for better understanding of hyper-
tension on the part of physicians and other members of the health care team. Their
enlightened participation is essential to the success of this national program. Although
we do not have solid information on which to base firm conclusions and plans, it seems
clear that a great many physicians are unwilling to undertake the treatment of hyper-
tension except in extreme circumstances. It's not too difficult to guess at some of the
reasons for this apparent inclination to undertreat the disease. The available hyperten-
sive agents produce a spectrum of side effects that can be distressing for the patient
and his doctor. Unless the physician is familiar with these side effects and can counsel
his patient and adjust the treatment regimen accordingly, he may very well find that
his patient stops following instructions, and his blood pressure goes back up.

Furthermore, as I mentioned earlier, we do not have firm agreement on the in-
dications for the use of antihypertensive drugs. Physicians are understandably hesitant
to begin a life—long regimen of therapy in a young adult whose blood pressure is only

mildly elevated and who shows no other signs of illness or disability. Until such

69

criteria have been established and widely accepted, there is bound to be some confusion
among physicians about what to do and a measure of unwillingness to do anything.

That plainly does not mean that our hands are tied, however, that we have to wait
for further research and scientific appraisals before anything can be done to enable
physicians to do a better job of coping with hypertension. There is much that can and
must be done now. In the first place, we need to get a clear picture of what the medi—
cal profession knows about hypertension and its treatment. Just how extensive is pro-
fessional understanding, and misunderstanding, about high blood pressure ? At the
same time, we need to develop the means of bringing authoritative information to
physicians and other health personnel so that they will be in a better position to provide
effective care to hypertensive patients. This educational effort, it seems to me, has
to be across the board. It will have to involve the formal teaching process at both
undergraduate and graduate levels; it will have to make use of continuing education of
health personnel; and it will have to be reflected in the information that health care
personnel receive from all sources — including the Food and Drug Administration and
other Federal agencies.

I said at the beginning of these remarks that FDA has a somewhat selfish interest
in this national hypertension program. We do, but it's a kind of selfishness that I
think is wholly justified. This program offers us, the FDA, a challenge to help build
an effective, two-way channel of communication with the medical and allied health
professions—a kind of communication without which neither we nor they can be fully
effective.

FDA is first and foremost a regulatory agency, but obviously we cannot regulate
in a vacuum. Our decisions regarding the safety and efficacy of drugs, antihypertensive
drugs for example, have the most telling impact not in the marketplace or the courts,
but in the doctors' offices and clinics where medicines are prescribed and the results
of their use evaluated. As a consequence, we need to make physicians and their co—
workers aware'of the scientifically established facts concerning the safety and efficacy
of drugs, and we need to learn from them what these drugs are doing in actual practice.
I hardly need to tell this audience that even the best planned and executed studies of

therapeutic agents cannot possibly reveal every effect a drug will produce, favorable

70

as well as unfavorable, when it comes into general use. For that kind of information
we are almost wholly dependent on those who use the drugs in practice — physicians,
pharmacists, nurses, and all other health personnel involved in patient care.

If this national hypertension education program leads to a better exchange of
information between the FDA and the health care community, even though that is far
from its primary goal, it will have accomplished an extremely valuable purpose from
our point of view. That is the pardonable selfish interest that we have.

Our interests, however, are assuredly not that limited. Let me just mention one
other opportunity that this national program can and ought to capitalize on. It is both
an opportunity and formidable challenge. Plainly, the pharmaceutical industry has a
high order of interest in a national program that, if successful, would mean additional
millions of Americans would become consumers of antihypertensive agents. That is
something the drug manufacturers would certainly, and justifiably, be glad to see. I
think the pharmaceutical industry, however, in collaboration with government, medi-
cine, and the voluntary health sector, has a more important role to play and the ability
to play it extremely well. It is an educational role, geared not simply to the marketing
of drugs, but to the saving of lives.

The drug industry has unparalleled resources for providing information to physi-
cians and other health professionals, and it also has the talent and resources to make
major contributions to public education efforts that are vital to the success of this
program. I am confident that the drug industry will see this national hypertension
education program as an opportunity to perform a vital public service by helping to
acquaint the professions and the general public with the facts about this disease.

A, The FDA is ready to work with industry, and with all the other groups that are
helping to get this national program in high gear, to make certain that no opportunity
is lost if it can contribute to the objective that brings us together today. Within our
own sphere of responsibilities — drug regulation — you may be sure the FDA will
bend every effort to make sure that useful antihypertensive agents, hopefully better
ones than we have today, will be made available as soon as they can be demonstrated
to be safe and effective.

Now suppose all of these efforts are successful. Suppose the level of public

71

understanding rises sharply and leads to a major increase in the demand for health
care. Suppose further that efforts to acquaint the health professions with up-to-date,
scientific informationabout the management of hypertension lead to a marked increase
in efforts to deliver services. What then? I am sure some pessimists would tell you
that the health care system would be swamped, that a massive effort to deal with
hypertension would be not the straw, but the boulder that broke the camel's back.

I am not such a pessimist. We have within the health care enterprise today the
resources with which to meet that challenge of hypertension, but these resources must
be utilized appropriately. We will have to see that full and effective use is made of
paraprofessional personnel; we will have to see to it that community health programs
are mobilized to deliver care for people who suspect they have, or do have, high blood
pressure. We are not talking about the creation of vast new resources, or the outlay
of vast amounts of money. We have the knowledge, the resources, and the capacity to
bring hypertension under control in this country. All we need now is the will. And if
we can muster that, the prognosis for high blood pressure will be a good deal better

than it is today — better than it has ever been for millions of Americans.

72

Responders

 

LABOR-RELATED SOCIAL AND PUBLIC POLICY ISSUES
IN THE
NATIONAL HYPERTENSION INFORMATION AND EDUCATION PROGRAM

Leo Perlis*

Since we in the labor movement know something about jurisdictional problems,
I hasten to assure our friends, the doctors in the audience, that contrary to all
rumors we have no intention of invading your turf. Obviously, we are not professionally
competent to determine the causes, cures, or even the consequences of hypertension.
We are prepared to take your word. We are not always prepared to take your word in
medical economics, but in this area we are. If you tell us that approximately 60, 000
people die from hypertension every year, we are willing to believe you. Certainly we
are not ready to take the count ourselves.

I have always wondered about the extent of hypertension among labor leaders.
One can easily imagine that participation in several collective bargaining sessions -
say for medical coverage, an item which, under the circumstances, comes readily
to mind - could cause a union official's blood to boil and perhaps even to zoom.

I am not saying this lightly, or because I am married to medical myths. I
am saying this to underline the importance of prepaid health insurance not only as a
major economic factor in the prevention and treatment of hypertension, but as an im—
portant psychological incentive as well. Without adequate medical coverage, no matter
how much you do in the area of cOmmunications and public relations, a great many
people are simply not going to go to their physicians for treatment. Without the
lowering of prices for drugs you are going to find much of your campaign aborted,
and without the use of generic names for medical pharmaceuticals you are going to
find your campaign limited.

But what can we do now to reach the 23 million adults who suffer from hyper-
tension?

We must begin with the truth.

I note that Dr. Marston, at the July meeting of the HEW Hypertension Infor-

mation and Education Advisory Committee, said that there is no cure for the disease,

 

* Director, Department of Community Services, AFL-CIO
73

but that we have the resources to control it. This, then, is what we should tell the
people. At the same meeting Dr. Marston emphasized the need to create an approach
to public education that will help people understand the nature of the disease, but, he
cautioned, without creating undue alarm. I am still inclined to cast my vote for
truth, even if it alarms. I suspect there are times when that is the precise function
of truth telling. It may even be therapeutic. In any event, it has been my experience
that people, in a democratic society at least, are more alarmed when the truth is
withheld from them. After all, despite rumors to the contrary, the American people
are not exactly children.

As laymen so often do - even those of us who have not been educated by
Reader's Digest — I recently engaged in a discussion on hypertension with a random
group of people, and these are some of the questions that came out of it:

1. What is it? Many of them had never heard of hypertension. They had
heard of blood pressure.

2. Do I have it?

3. Can I get it?

4. How does one get it?

5. Is there a cure for it?

6. What do you do about it?

7. How can I prevent it?

That's a good group of solid questions, and under the heading of Information direct
answers should be made available to the people by competent medical authorities.

This, of course, requires the involvement of people through their own organi—
zations at home in the neighborhood; on the job in the mine, mill and office; at the
store; in the marketplace and shopping center. Thus, the information will permeate
the total community and will reach every individual where he lives, where he works,
and where he shops. The full use of the press, TV, radio, posters, pamphlets, and
other printed and electronic media will help, of course, but the major emphasis must
be placed on the people's organizations. In the case of employees, unions must be
involved from the group up; in cooperation with management, they must be given the

opportunity to assume equal responsibility for a national hypertension program in

74

industry. Union—management cooperation through joint committees is essential.
But, here, however, confidentiality must be maintained. A great many employees
are fearful of losing their jobs should they be discovered to have blood disease or
high blood pressure. Job guarantees must be assured and secure. Health insurance
coverage must be sustained, and workmen's compensation must not be used by
employers to inhibit their employees from seeking information about their state of
health or from seeking medical assistance when their state of health requires it.

Still, involvement is not enough. In fact, involvement is probably impossible
without incentives. We all know that relatively few people are sufficiently motivated
to engage in preventive health practices. Almost all people, I suspect, visit physicians
when they think they‘re sick and not when they feel they're well. What, then, are the
incentives for mass testing? None that I can see except better health and a longer life.
It is, of course, possible to stress the reverse — namely, sickness and death. If this
is the case, then this is what we must say on posters, on TV, on radio, at meetings —
everywhere. And it must be said by all of us — governmental bodies, voluntary agencies,
unions, management, medicine — everybody who is involved in this national campaign.

Let us assume for one moment that everything is going well. The information,
or the truth as we see it, is all around us. The incentives, either positive or negative,
are within us. Insurance (presently limited mixed voluntary, but soon, I hope, compre—
hensive national health security) covers us. Still, what does one do after he is tested
in his firehouse, in his plant, in the shopping center, in his school, in his church, in
the doctor's office, under union—management auspices, under civic and fraternal
auspices, by doctors, by nurses, by aides, or even by Secretary Richardson? What
does one do?

Instructions are what he needs — precise, positive and specific. He does not
need an understanding sensitivity session or a philosophical discussion on permissive
behavior. He needs a doctor who knows his stuff and who knows how to tell it, as
they used to say in the ungrammatical sixties, like it is: You either want better health
and a longer life, or sickness and death. The choice is yours. If you want the first,
this is what you must do. If you want the second, do nothing. That's all there is to

it — except for one thing.

75

Nothing raises my own blood pressure more than businessmen and others
(including doctors) who promote conferences and all kinds of programs on mental
health or alcoholism or drug abuse or hypertension for the sake of more production
and productivity, or less turnover and absenteeism. These are all secondary by-
products. We should all be more concerned, after all, with human lives saved ‘
than with man hours lost. The end product of a healthy human being is a healthy
human being. Therefore, please don't anyone promote programs for the prevention
and treatment of hypertension for the sake of anything except the prevention and treat—
ment of hypertension and a longer, healthier life. This should be dogma for anyone
who, in this connection, is neither pro- or anti-management nor pro— or anti—union,
but simply pro-patient.

If this is what we want to do, then what we need are information, involvement,
incentives, insurance and instructions - the five "i's" that will not make us immortal,

but perhaps just a little less mortal.

76

HYPERTENSION AND THE PRACTICING PHYSICIAN
Ray W. Gifford, Jr., M.D.*

The demonstration that effective antihypertensive therapy will prevent or fore-
stall cardiovascular complications and prolong life has thrust hypertension into the
forefront of public health problems facing this nation. Although the solution of this
problem will ultimately depend on the medical profession, including allied health per-
sonnel, many disciplines must be enlisted to combat this menace to cardiovascular health.
Among those who must become involved are educators, behavioral psychologists, health
planners, public officials, legislators, media experts, leaders of industry and labor,
and the consumer himself. I am pleased that many of these groups are represented here
today.

From the standpoint of the medical profession, the most immediate need is a
large scale effort to inform physicians that hypertension is a serious threat to the cardio-
vascular system, and of equal importance, that effective treatment will reduce the risk
of cardiovascular complications. Strange as it may seem, for decades physicians
accepted hypertension with unwarranted indifference. Hypertension was called "essential"
because it was thought to be essential for normal body function in some patients. I think,
most physicians now recognize that hypertension carries with it a poor prognosis for
health and longevity, for the reasons Dr. Stamler eloquently identified this morning.

It is certainly the most important predisposing factor in coronary disease and in stroke,
which together account for more than 50 percent of the deaths in the United States today.

We know that treating hypertension will indeed prolong life and forestall these
complications, but the fact that only 10 or maybe 15 percent of all hypertensives in this
country are being treated adequately indicates that physicians are not yet convinced that
treatment is beneficial. Many medical specialists, such as otolaryngologists, psychia-
trists, dermatologists, pediatricians, urologists, ophthalmologists, orthopaedists, and
even some general surgeons do not routinely take blood pressures on new patients. I
would be willing to wager that of all the hundreds of thousands of people that visit physi—

cians' offices this very day, less than 50 percent, and maybe much less than 50 percent,

 

* Director, Department of Hypertension and Nephrology, Cleveland Clinic, Cleveland,
' Ohio
77

have their blood pressures checked. The concept of considering every physician's office
as a "screening station" for hypertension should be promulgated. While these specialists
should not be expected to manage hypertensive patients that are discovered in this man- I
ner, they should assume the responsibility for referring them to appropriate practitioners
who can manage this disease.

What about the manpower shortage? There are those who believe that there is
already a shortage of physicians in the United States. What will happen when fifteen
million untreated hypertensive patients seek the professional care which they deserve?
The training of more physicians is not the immediate solution to this manpower shortage.
I would like to make the following proposals which will make better use of existing man-
power until such a time as more physicians can be adequately trained:

1) The medical profession and the public must learn to employ and accept

well-trained allied health professionals working under the close supervision of

a physician. Such allied health professionals include nurse practitioners,

physicians' assistants, and even trained'neighborhood health workers. Without

allied health professionals we can never get the job done! These professionals
can be used very effectively in screening, and to some extent in managing,
hypertension under the direction of the physician.

2) In the past, too much emphasis has been placed upon the extensive and

time—consuming diagnostic aspects of hypertension, and too little emphasis on

the importance of medical control of this disease. Streamlining the diagnostic
aspects of hypertension will permit diversion of manpower, facilities, and
economic resources to the greater task of screening and treating, without sac-
rificing quality of care.

3) Patients and physicians alike in this country are accustomed to seeking

or giving medical care according to what hurts; physicians and patients do not

have the concept of preventive health care - of life-long treatment for asymp-

tomatic disease in an effort to prevent dire complications. This represents a

big job in education, to change our concept of what medical care is all about.

The treatment of minor illnesses which consumes so much of the physician's

time should be delegated to trained allied health professionals, permitting the

78

physician to devote more time to more serious problems such as hypertension,
which, though asymptomatic, are a greater threat to the patient‘s future than
are viral respiratory infections, sinusitis, functional bowel disorders, and
hemorrhoids !

4) Serious consideration should be given to the establishment of peripheral
health stations manned by nurse practitioners, physicians' assistants, and other
trained allied health personnel. These health professionals could be trained

to manage many types of chronic disease, including hypertension, after the
physician has evaluated the patient and initiated the appropriate therapeutic
regimen. It is not necessary for a physician to see a hypertensive patient each
time he comes in to have his blood pressure recorded. Such peripheral health
stations would alleviate crowded conditions in physicians' offices and would free
more time for the physician to evaluate new patients and get them started on the
indicated therapy. Hypertensive patients would report symptoms which would
then be relayed to the supervising physician for his advice. The nurses and
physicians' assistants could instruct the patients in taking their own blood pres-
sures if this were the desire of the primary physician, and could alter doses of
medications under his direction. This concept has been advocated by the Hyper—
tension Study Group of the Inter—Society Commission on Heart Disease Resources.
I think it could save the physician enormous amounts of time.

5) If this concept of wider use of allied health professionals is to be success—
ful — and it must be if we are to cope with a problem of the magnitude of
hypertension in this country — the federal government and private insurers
must recognize the value of these trained health professionals, and must permit
payment for services rendered by them under the appropriate supervision of

the physician. To demand that the patient be seen by the physician each visit

is to defeat the purpose of this proposal.

6) Record keeping is becoming an increasing burden to the physician, di-
verting his time from patient care. He has a lot of forms to fill out — not only
records of his patients — and the more patients that are covered by third party

carriers and government insurance, the more time he must spend filling out

79

forms. Insofar as possible, office records should be simplified, and at the
same time clarified. Use of special therapy sheets for recording blood pres—
sures, drugs, and side effects should be encouraged. Simplified, uniform
reports for filing insurance claims must be devised and universally accepted
if the physician's time is not to be consumed by completing insurance forms.
The problem of patient compliance is one of the foremost obstacles to manage-
ment of chronic asymptomatic disease. While an interested, sympathetic, and knowl-
edgeable physician plays an important role in convincing patients to adhere to life—long
therapeutic regimens, the medical profession by itself cannot assume the entire respon-
sibility for patient compliance. I would hOpe that with the combined efforts of media
experts, behavioral scientists, and public relations people, we can get the message to
the people that treatment of hypertension is beneficial. I just hope that we are more
successful in persuading patients to take antihypertensive medication than we have been

in persuading them not to smoke cigarettes!

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CONSUMER-RELATED ISSUES
IN THE
NATIONAL HYPERTENSION INFORMATION AND EDUCATION PROGRAM

Mrs. Earlean Lindsey*

Since we are here fighting high blood pressure, and today is a special kind of day
for me because it's Dr. King's birthday, I am going to ask a favor of you. There's a
song that goes "reach out and touch somebody's hand, let's make this world a better
place. " Why can't we all just stand up and shake hands with our neighbors, and say
happy birthday, Dr. King?

(Audience Participation)

That wasn't so bad, was it?

I was asked to prepare a presentation, but I think most everybody knows that's
something I can never do. Unless I look at individuals I just can't get it together to
know what I am going to say, and I always depend on that little supreme being some-
where to give me the words to say to fit the occasion.

When I look at this audience I notice that since the Community Action Program 3
started the complexion hasn't changed one bit. It is still all white. Yet we are talking
aboutblackdiseases and black crises. The first thing that comes to my mind is that
we are preparing ourselves for the next election; we sickle celled to death the last
election. It strikes me strange that there's never a white disease that causes a white
crisis. It's always a black disease, and yet black people are never allowed to deal
with the crisis; they are never given research money to do the research for the crisis.

One of the questions Ihope we all address ourselves to this afternoon is what are
the determining .factors in establishing crisis. It seems strange that with all of this
knowledge that you have been holding so dear you haven't done very much with it. Are
you afraid to share it? That's the reason we have a crisis: it's the lack of knowledge.
Unless we learn to really share whatever it is that concerns individuals then we are
always going to be reacting to a crisis.

A couple of years ago there was a proposal submitted to HEW by two black national

organizations. They played games with it until last year. I am going to take just a few

 

* Community Organization Specialist, Mile Square Health Center, Chicago, Illinois

81

minutes to read you just a little bit of the content of that proposal. I am going to do that
because Iwondér why people like Secretary Richardson and many of the others at the
Federal level that dump millions and millions of dollars into health care that never
reaches the people, are not willing to accept a new model that is turned around. The
same material is being uSed here today when we talk about setting up educational com-
ponents to high blood pressure.

"The National Consumer Coalition is essentially a community program consisting
of and working for low income health consumer groups in association with providers to
provide health education, training and technical assistance so that the low income con—
sumer can participate more effectively. The program will accomplish its goals through
regional areas and local communities with educational instruments which will enable
them to detect and determine community health need, health educate the consumers,
mobilize local and regional resources to assist in the problem solving process, educa-
tion and organization. The Coalition and its structure has been designed to provide tech—
nical assistance to all groups" -— not a word about color. Some of the following are
examples of criteria which might be used in evaluating community projects:

1) "Measurable increase in health related information, health and health related
boards. " That meant put some consumers on these hospital boards, and maybe
the physicians and the pharmaceutical companies will quit controlling health
care costs.

2) "Measurable increase in actual utilization of available health services to the
poor, participation in health programs of their own. " Nobody ever comes into
a community and asks, "Community, what do you see as your health needs ?"
The need has been established when it gets there. The money that has been
left from setting up different subcommittees to run the little money that we get
is not enough.

Short range funding of one year is always a problem. They took the neighborhood

health center concept and ran it until they got through brainpicking and nitpicking and
they got everything they could get out of it, and look what's happened to it now. If that

money had been approved on a five year basis, a guaranteed amount and not negotiable

82

each year, I wonder how far neighborhood health centers Would be now instead of in the
crisis they are in.

Another problem is that in preventive care we only look at the medical aspects.
We never touch bases on inadequate housing, unemployment, the kinds of things that
concern a person's daily environment. The neighborhoods haven't changed; nothing
else has changed in the community. We are trying to get people well, but sometimes
I wonder for what.

The good Doctor talked about educating physicians. Until the medical schools
build into their curriculum a component that deals with race relations, differences in
individuals, and communication, then we always as a nation will be reacting to health
crises.

I think these are the kinds of questions that we are going to have to talk about if

we are really talking about attacking the problem of health care.

83

 

HYPERTENSION AND MEDICAL EDUCATION
J. Willis Hurst, M.D.*

Hypertension and medical education. I will take each of these words and discuss
them separately. Views regarding hypertension are often controversial; views re-
garding medical education are even more controversial. Put the two subjects together
and there is no way to avoid controversy. I do believe, however, that we are entering
an era where the controversial aspects of each subject will be altered; the discussions
will be different. The problems in hypertension and in medical education are now being
attacked with new insight and vigor.

I will divide my remarks into three parts. Part one deals with the last word,
education. I will make comments about educational institutions, about education gener-
ally, and about educated persons. I hasten to add that I certainly cannot speak for all
educational institutions or all educated persons; this is my own bias.

An educated person is one who knows how to learn and continues to do so all his
life. An excellent educational institution is a place where people who work there assist
others in developing an ability to learn and encourage them to do so forever. The spirit
of learning prevails in such institutions. The job of individual discovery must be main—
tained in such an institution, for it is the sustaining force that encourages the self-

discipline of long term learning.

The definitions of certain words become critical when one attempts to communi
cate about this subject. The fact that someone has memorized a set of facts and scored
100 on an exam designed to determine if he really did memorize all the facts does not in
itself prove that the person has learned anything. Learning takes place when there is a
change in the behavior of the person doing the learning. The person who is learning is
constantly placing the facts he memorizes into new arrangements. In this way he grows,
and can continue to grow. The recall of facts memory is important, but it is not learning
and cannot even be sustained unless the facts are used. Witness our difficulty in speaking
a foreign language even though we scored satisfactorily on an examination in the subject.

Fortunately, many institutions are beginning to encourage the manipulation of facts that

* Professor and Chairman, Department of Medicine, Emory University, Atlanta, Georgia

85

have been memorized rather than dwelling solely on the facts per se. When the cognitive
school of learning is linked to the behavioral school of learning the place literally vi-
brates with the spirit of learning.

Part two: comments about health education.

First, I do not believe that there can be an excellent health care system without
excellent health education. This has been alluded to all day. Second, health education
for the public should begin in the first grade and continue in every grade of grammar
school, high school, and college. After leaving high school or college — where he
should have learned how to learn — an individual should be offered continuing educa-
tion programs by his employer in many areas — including health education.

Three, the preceding plan would require many decades to implement, but we
must start. What can we do now? Industrial institutions could develop educational
programs for the people who work there. For example, a bank where a hundred
people work could have an educational enrichment program which would include health
education. If they couldn't mount the program themselves then at least they could
arrange for it. I believe there are many physicians, nurses and others who would be
willing to participate in such a program. To make my point, I have known of voluntary
health agencies dealing with health, I have known of hospitals where 2, 000 people work
that have no educational health program for those people who spend their lives working
in the area of health.

The waiting room of every physician's office and every hospital should be
developed into a health education center. Pamphlets and health materials generated
by organizations such as the American Heart Association, Cancer Society, and Heart
and Lung Institute, might be made available to those who wait there. You know what
they read now. Modern technology, including television, could be used as the area
assumed its role as an educational center.

Four, medical education is changing in the following ways: No institution
believes it can teach everything to its students; the View that the student physician,
student nurse, and allied health student can learn everything has now vanished. Such
institutions now believe that their objective is to lead their students to learn how to

learn medicine. The institution should ask, "Are our students learning how to learn

86

so that their process of learning will continue after they leave the formal walls of this
institution?" More and more effort is being spent linking the cognitive school of
learning - that is knowing something, knowing about hypertension — to the behavioral
school of learning — doing something with the knowledge. The internship and residency
program for physicians and the early years after the nurse or allied health person
graduates must be further years of problem identification and problem solving, where
skilled people guide the refinement of the learning process.

All the preceding are pulled together in the problem-oriented system of edu-
cation and patient care. This system, devised by Dr. Lawrence Weed of the University
of Vermont, brings to life all the philosophical points made earlier and binds together
all the fragments of medical care into one vehicle. Those who view his very teachable
system in a superficial way will not see this, but those who work with the system see
it as the key to future medical education and patient care. The system takes informa—
tion or knowledge and translates it to action, which I would gather is the problem we
face.

The problem-oriented system consists of three steps: One, the creation of
a problem-oriented record. Dr. Gifford alluded to the fact that if you want to evalu-
ate what you are doing you had better have a record that allows you to inspect what you
are doing. The problem-oriented record has four parts. One part is the collection
of medical data from a patient. Two, the formulation of a complete problem list which
is numbered and titled at the level of the physician's understanding. This is placed
first on the patient's record. Three, the development of plans for each problem re—
quiring further attention. The number and title of each problem are obtained when
the plans are written; therefore, a coding system emerges. Four, a follow—up prog—
ress note, numbered and titled just as it was on the problem list, is written for each
of the problems. This makes it possible for any other doctor, any nurse, any allied
health person, to go through a record step by step and see if the essential elements
are present which allow one to translate what he knows into action. Four simple
steps. Again I state that if we know a lot about the management of hypertension the ball
game will be won, as we will be able to translate what we know into behavioral per-

formance action.

87

Part two of the problem-oriented system is known as audit, which means to
inspect and evaluate. In order to do this it is necessary to set up a standard of work
that is deemed excellent and defensible. This should be taught to all concerned. The
problem-oriented record is then inspected to determine if the excellent work is indeed
being carried out. Any discrepancies which might be there are therefore identified.

Part three of the problem-oriented system is the correction of discrepancies
found in step two. My own particular work is centered in this area because it is clear
to me that the techniques used in the past to correct discrepancies, such as lectures,
do not produce the desired result. We must find new ways to insure that we indeed
correct discrepancies. Lecture is the simplest way, but if you audit the performance
following lectures, you will find the half-life of the information drifts very, very‘
quickly into 48 hours — including the lecture I am giving you now.

The problem—oriented record is used by all health workers and the patient. The
nurse, physician's assistant, nurse clinician, and so forth, must learn the system and
be able to learn from and record their observations in such a medical record.

I cannot discuss all aspects of the problem-oriented system today, but one item
must be mentioned in light of our subject. A new word has appeared on the scene. It
is known as algorithm. An algorithm is a pre-defined step—by—step series of actions.
It may be an educational algorithm prepared by a group of experts to be executed by
one skilled in following an algorithm; it may be a diagnostic or a therapeutic algorithm
created by one group and executed by another. It is through this that allied health people
will be able to participate; algorithms will be set up, followed by allied health people,
and recorded in the problem—oriented record. A little more of that later.

Part three of my discussion deals with hypertension in the context of the previous
parts, part one being medical education generally, part three hypertension within that
context. .

Number one, decades from now let us hope that every school child will know more
about his body, including something about blood pressure. Two, let us hope that all in—
stitutions will assume more responsibility for health education for the people who work
in the institutions. Each institution should cooperate with organizations such as the

American Heart Association. I bring up the Heart Association simply to point out that

88

there is a network across this country of Heart Association affiliates which I can assure
you will be glad to work vigorously to help create a system of education and patient care
in hypertension.

Three, :he waiting rooms of physicians' offices and hospitals should be educational
centers, including the dispensing of information about hypertension:

Four, the problem-oriented system of education and patient care should be taught
in medical schools and hospitals, and should be used throughout the health delivery
system by all health workers.

Five, we must realize the following: We still don't know enough about hyperten—
sion. We know a great deal more than we did, but I would point out that every speaker
has mentioned the toxic effects of drugs. I would still hope that there might be less
toxic drugs in the future. For example, what will reserpine do in a 20-year haul to
people, since we know that it increases the frequency of mental depletion, suicide, and
a number of matters of this sort? The point was made that the benefit to be gained
today would appear to be greater than the toxic effects created by drugs, and that is
correct. This does not mean that we should not pursue the search for additional and
better drugs. Basic research must continue, because the treatment for hypertension,
while better than it has been, is still not ideal.

Highly skilled individuals will be needed to guide the care of the hypertensive
patient. Note I said gtgdgthe care. Extensive and prolonged training will be required
for such individuals, else the quality of care will be less than desired. Note again I
said guide the care. If a physician is to have many allied health people under him,
operating under algorithms he and others have generated, all recording in a problem-
oriented record so one can audit what they do, then I would point out it takes highly
skilled people to manage the system.

Experts must clearly define several items. These sound very peculiar, but they
are questions that come my way despite all that has been written: How does one determine
the level of blood pressure? Do you do it three times and wait 15 minutes between each
time? Do you do it recumbent, standing and sitting? Do you take it in the legs every
time? These simple things have to be specified. At what level of blood pressure is

one justified in calling the pressure elevated? Now that is reasonably clear, but there

89

are still arguments. Which patients need an extensive medical work-up? Which
patients do not need an extensive medical work-up? What is an extensive medical
work-up? Patients fall into categories. What work-up is proper for patients who fall
into certain categories? Since most patients with high blood pressure have so-called
essential hypertension, hypertension of unknown cause, would it be wise for us to
develop a system, a strategy, if you will, where a detailed work—up is given only to
treatment failures rather than to all initially? What is the strategy on that, and has
it been spelled out carefully? Algorithms for management must be written by experts
and executed by allied health workers whose work can be monitored or audited when
they record in a problem-oriented record.

Finally, I believe we are entering a new and exciting era of medicine and medical
care. We must retain and improve the quality as well as the quantity of care. Learning
systems and patient care systems are being blended together now. The ability to trans-
late what we know to the care of the patient can really become a reality, but please
remember we don't know enough. More basic research is needed. Remember, too,
that if allied health personnel can execute algorithms generated by physicians, we need

many highly trained physicians to guide the system.

90

INSURANCE, OCCUPATIONAL HEALTH, AND HYPERTENSION
Leon J. Warshaw, M.D.*

I am delighted to be here for a variety of reasons, the most important of which
is that I have been laboring for most of my professional life with a primary focus on
the prevention of illness, morbidity and mortality, and it is nice to welcome so many
new people to the game. If I may inject a note of skepticism, and to tell it like it is,

_I have had the feeling all the time that I was playing in a game not even in the intra-
mural leagues, but in the scrub, sand lot game. ' I think that with this conference we
are getting together and putting on shiny uniforms with numbers on the back. It remains
to be seen whether we are going to get into the stadium and into the real ball game. I
trust we will; I sincerely hope we will. Perhaps the most auspicious and significant
aspect of this program is the fact that it represents the collaboration and coordination
of the broad variety of interests represented at this conference. If nothing else augurs
for its success, that certainly does.

There are a number of important considerations I think that need to be looked at
in designing and guiding this program. Some have been alluded to by previous speakers;
I will only touch on them in passing. Perhaps the most important element is the fact
that we are interested in people, and not in blood pressure as an abstraction. Other
speakers have referred to the physicians' relating and listening and talking to the patient.
We too often tend to get involved in numbers, which are relatively meaningless.

Effectiveness of the program demands that it be continuing, and not just a one-
shot political activity. It takes effort over a long period of time to persuade an appar-
ently healthy individual with no complaints to change his life style and to pursue a
course of treatment to control blood pressure elevation that otherwise might cost him
years of life in the distant future. It takes more time and effort to keep him at it.

There must be continuing work to delineate the various types of so-called essen-
tial hypertension —- not just to lower blood pressure. We must continue to explore
new and better forms of treatment. When I say new and better I mean more effec-

tive treatment, less costly in terms of side effects and restrictions of life style,

 

* Vice President and Chief Medical Director, Equitable Life Assurance Society of the
United States, New York, N.Y.

91

.more economical in terms of dollars, and more important in terms of the personnel
and facilities needed for treatment.

Finally, we must measure the impact not by reduction of blood pressure, but
in terms of reduced morbidity and mortality.

To provide a basis for such evaluation, I propose that the program consider
the establishment of a centralized national data bank in which individuals identified
as hypertensive could be registered and classified and periodic entries made of the
kinds of treatment they are receiving or not receiving and of the short-term results
being achieved. Ultimately these would provide significant analyses of the value of
the treatment in relation to morbidity and mortality. They would also be particularly
useful in view of our mobile population, which not only moves from place to place,
but from doctor to doctor — many times I think with good justification. Also the
periodic request for updated entries would provide a useful reminder and stimulus
for follow-up and continuing treatment. Naturally, appropriate measures have to be
made to safeguard the confidentiality of personal information while making the collec-
tive material fully available to qualified research experts.

From the standpoint of industry and occupational medicine, as you heard from
Dr. Stamler, screening programs are already under way through the various exami—
nations being performed in industry. We need better follow-up of the results of these
examinations, but they are being done increasingly. Occupational health programs in
company medical departments, union health centers, industrial clinics, and so forth,
represent an underutilized resource for screening, education and treatment, however.
Their successful application involves the cooperation of labor, voluntary agencies and
community. All of these together could initiate a program which would be successful.

Industry is concerned about mounting evidence that exposure to certain environ-
mental contaminants such as lead, cadmium, and zinc are causative factors in hyper—
tension. Long-term low-level exposures that do not produce immediate toxicity
appear to be associated with significantly increased mortality from hypertensive
heart disease. It is only now that we are beginning to assemble this kind of informa—
tion. It is odd that with the collection of national, federal, and HEW agencies repre—

sented in this meeting that the National Institute of Occupational Safety and Health is

92

not listed. I certainly hope that this omission is corrected in future meetings of
this kind.

Industry is also concerned that a much more persuasive pollutant, emotional
stress, is implicated, if not in the causation of hypertension, then certainly in its
aggravation. One need only look at the upper echelons of HEW in the last month or
so to see how this might be a problem. Thus the specter of labeling hypertension as
an occupational disease is raised with all that it implies.

One argument against screening programs in industry mentioned earlier is
the fear that identifying an individual as a hypertensive may be the basis of refusing
to employ him or refusing to promote him. Unfortunately, this does occur occasionally,
but usually under circumstances in which the decision is already made for other, and
perhaps less acceptable, reasons. In most companies — certainly in most large and
enlightened companies — there is no discrimination against employees with asympto—
matic or adequately controlled hypertension; in companies with well established occu-
pational health programs there is indeed an active search for such individuals, and a
strong effort made to educate them as to the advisability of treatment. The important
gap lies in the referral to the physician in the community at large, where the ball is
usually dropped.

There are, however, instances when considerations of public safety dictate
enlightened judgment in the placement of individuals in jobs where the side effects
of drugs or other treatment might result in harm to themselves or to others. These
instances must be considered an acceptable price to pay, but great care must be taken
to see that the decisions are made objectively.

With respect to life insurance, elevated blood pressure is one of the health
factors most frequently considered in risk evaluation, and as you heard from
Dr. Stamler's collected data, with good cause. However, individuals with modest
blood pressure elevation and no evidence of complications or other underwriting risks
are often issued life insurance at standard rates. Others are required to pay additional
premium commensurate with the actuarially determined risk created by their level of
hypertension and all other factors affecting morbidity and premature mortality. Most

carriers are constantly revising their underwriting standards. Effective control of

93

hypertension over a period long enough to assure it is being sustained will often be
reflected in a reduction of these extra charges. In time successful reduction of
total mortality from hypertension will be translated into premium reductions for the
entire population.

Incidentally, the great majority of individuals today are covered under group
life insurance or in the small amount policies which are issued without medical limi—
tations. Discovery of hypertension will not result in lowering individual premiums,
while national control of hypertension will result in lower rates for all.

With respect to health insurance, this program could present some very
serious problems. The additional examinations and treatment required by the millions
V of individuals presently unaware of their blood pressure elevation will have a signifi—
cant impact on health insurance costs. In time this will be offset by diminished mor—
bidity among the successfully treated hypertensive individuals, but for the short term
there will be an extra strain on the health care delivery system.

This leads to a very difficult moral, economic, and political question. Since
our resources are not unlimited, hard decisions will have to be made on a national
level — such as whether we spend a million dollars to provide renal dialysis that will
add one or two years of life to perhaps 20 or 25 individuals with end-stage kidney
disease, or whether we spend that amount, in early preventive treatment that will add
ten to twenty productive years to the lives of 500 individuals. This calls for exquisite
and courageous judgment.

I have summarized some caveats, some questions, some concerns, but none of
these really outweigh the potential benefits to all of society from the successful imple-

mentation and pursuit of this program. I think to all of those who hear our words,

the word is go.

94

MEDIA-RELATED ASPECTS OF THE
NATIONAL HYPERTENSION INFORMATION AND EDUCATION PROGRAM

Thomas J. Deegan, Jr. *

Since early this morning the recurring theme here has been in effect that the
facts about hypertension, high blood pressure, must be told; how can they, how should
they be told. My remarks as a responder today will detail those elements that I think
need to be started immediately to effect a major national public education program for
the treatment of hypertension.

My initial analysis of the subject has convinced me that hypertension's treat—
able nature embodies a sound overall program theme. The general public has been
somewhat desensitized to disease alarms. They cannot round a corner of their daily
existence without confronting a major health threat; cancer, heart disease, kidney
malfunction, multiple sclerosis, hazard their lives like a minefield. Although they
have been educated to recognize signs of illness, very few of these are negotiable once
the person falls victim. This atmosphere very likely stimulates a growing public
inclination to reduce anxiety by simply turning off — "what I don't know can't hurt me. "
Given such attitudes, we must make every professional, educational and communi—
cations effort to establish the fact that hypertension, though potentially serious, can
be treated. A national consciousness must be developed at all levels of society, all
ages, to encourage the diagnosis of hypertensives. Then a program of painless,
simple treatment can be begun to facilitate long and full lives. Our overall theme,
then, should be "hypertension, the treatable health threat. "

I would recommend a program with three main phases: the first phase would
concentrate on informing, preparing and stimulating support from those people and
groups who are respected sources of health information. In many cases such persons
can actually aid in detection and treatment of the disease. Doctors, dentists, nurses,
pharmacists, and all other medical support professions comprise one such group.
They must be thoroughly convinced of the priority of the danger hypertension repre-

sents, of the opportunities and obligation they have to inform, and of the simple

* President, Thomas J. Deegan Co. , Inc. , New York, N.Y.

95

diagnostic and remedial procedures currently available. The recent Harris poll confirms
the major position these people occupy as health informants who are trusted and listened
to by the general public. Of eight target publics identified, half would already be under

a doctor's care. We must be certain that our program capitalizes on such situations in
this effort to educate the public on a broad basis.

We must also reach and gain the cooperation of other groups who similarly, by
their normal activity, dispense health information and care. We would include in this
group insurance companies, corporate personnel directors, labor unions, and those
public agencies whose licensing functions incorporate health assessment. One other
group would be included in this phase — the persons who supply those we have men-
tioned with information: the writers and editors of medical and dental journals, in—
house publications, and the pharmaceutical and insurance companies' publications.
They must be convinced of our program's importance and of their obligation to trans-
mit our message. During a six months' period meetings should be arranged to coin—
cide with the major conventions these groups have scheduled. I believe someone is
already at work on that.

We should reinforce the program advocate's presentation with a comprehensive
information package that would contain current research activity, simplified diagnostic
and treatment procedures, a complete description of the national campaign, and a sam-
pling of the material that would ultimately be used in this campaign. I also recommend
that an ongoing brief communication vehicle be created and initiated at the start of this
phase and mailed regularly to the groups concerned. This vehicle would be an up—to—
the—minute status report of progress and effort being made in the fight against hyper—
tension, or the treatment of hypertension. This vehicle, a printed publication, perhaps
titled "Hypertension Hotline, " would be issued quarterly; its format would be extremely
brief, no more than two typewritten pages of information. It would be our open line to
this important group and sustain their enthusiasm, interest and knowledge. These two
activities would underwrite a low-key effort that would inform and stimulate pivotal
groups who would not only help transmit our message to the general public, but might

also handle the response to that message.

96

The next two phases are distinguished only inasmuch as one is a small scale
test of the activities and approach of the other. A three-month test should be made,
in a controlled situation, of all activities and techniques that are planned for the
national level program. For example, Washington, D. C. would seem to be an ideal
location. It has a large black population, a heavy concentration of public information
media, plus a favorable proximity to research facilities and the federal government's
own health headquarters. Such a test would enable us to evaluate the proposed national
program and to see what portions should be modified or intensified to increase its
effectiveness. Since this test phase would utilize the same activities as the national
campaign, we will simply note that such a test would serve as a microcosm, using
proportionate amounts of activity.

The national program, going a step further, must be fueled by two components:
(1) paid print and broadcast advertising; (2) public information activity. Advertising
should reflect and amplify the theme "hypertension, the treatable health threat, " and
its component variations. The greatest share of this effort should be invested in
short, simple broadcast messages to suit the general public's heavy broadcast orien—
tation. Radio and television spots, billboards, newspapers and magazines should, of
course, be employed in the order listed.

The amount of money budgeted for advertising and the overwhelming need for
imaginative talent to be infused on a high priority basis indicates that the advertising
should be entrusted to what is known professionally as a smaller advertising agency,
as distinguished from one of the giant advertising agencies where the availability of the
top level creative executives would be less realistic. A so-called smaller agency
would optimally treat such a program as a major account that represents a national
showcase for its best efforts. The public information element of the program involves
the creation of specific media —- brochures, pamphlets, slides, educational films —
and the use of public media to accommodate the program's nature, purpose and theme.
The specific media are designed to present our message in those situations where
the general public is concentrated and particularly when it is likely to be predisposed

to receiving that message.

97

A brief, simple film should be created that would describe the danger hyper-
tension poses, explain the diagnostic procedure and emphasize the favorable prognosis
for those who submit to medical care. The film would be designed for use in cartridge
players that would be located in doctors' and dentists' waiting rooms and in public
transportation depots, among other places. The initial survey indicates these player
machines are already used by many doctors and dentists. Other outlets could be
supplied with the machines on loan, rental or lease basis depending upon demand and
circumstances.

There should be design mobile units that would move through high density
population areas equipped to dispense information and to test/ screen people who pre—
sented themselves. The unit would have sound-track capability to attract attention
and be staffed with personnel equal to its two principal missions. These units should
be used in principal cities initially, and, if they prove successful, their number and
scheduling should be expanded.

The program should also draw upon the establishment and staffing of informa—
tion centers, storefront units, in the business districts of large cities. These centers
would not only furnish information and diagnostic opportunities for the general public,
but they would also serve as supplemental information resources, by phone and mail,
and be capable of meeting general news media requests for information at the local
level. The effectiveness of both the mobile units and the information centers should
be monitored to determine whether these could be used to advantage in large shopping
centers or at public recreational events - circuses, county fairs, sporting events.

The national program would also seek the cooperation and involvement of the
pharmaceutical and insurance industries, among others. They would be encouraged
to include hypertension as a theme in their institutional, public service advertising.
An immense amount of print and electronic advertising could be developed paid for
by independent organizations, corporations and other interested parties which would
represent in effect substantial advertising dividends.

A central information function should be activated during the national level
program. It would be responsible for continuous news feed to all media and for

coordinating the public information function. From a physical standpoint, the public

98

educational program should be headquartered in New York with a strong supporting
office in Washington. These are the two media nerve centers. It is also very
important that close coordination be maintained between the information officers
within HEW so that full strength of communications and accurate data is maintained.

The national program should be reinforced by information materials and events,
all of which would have a feedback component. Leaflets should not only alert the
public, they should be couponed for aid and further information. A nationwide TV
documentary — this might well be developed as a public service project by working
with the Advertising Council — that would call for audience participation should be
designed. A Speakers Bureau should be formed using as advocates those people who
have hypertension and have continued to lead active normal lives — for example, men
like Senator Stuart Symington. Continuing efforts should be made to alert the public,
develop their use of diagnostic opportunities and support their observance of remedial
medical treatment.

The first year's activity should be focused entirely on sounding the alert, making
people aware. In the second year perhaps thirty percent of the effort should be allotted
to compliance, encouraging people to follow doctor's orders. In the third year and
every year thereafter equal attention should be given to both these elements. From a
practical view a mass public education program of this scope should have a minimum
budget of $10 million to cover the project for the first year, broken down into paid
advertising, covering print and electronic media, $9. 5 million; $150, 000 for market
research, and $350, 000 for the non-paid advertising portion of the educational and infor-
mational program. The budget must be reviewed for each year thereafter. Speaking as
a professional in my field, I believe this program would effectively achieve the objectives

that have been identified by the Hypertension Program Advisory Committee.

99

 

Appendices

 

AGENDA

NATIONAL CONFERENCE
ON
HIGH BLOOD PRESSURE EDUCATION

Washington Hilton Hotel
January 15, 1973

Registration

January 15 — 8:00 a.m. to 9:50 a.m.
Concourse Level Lobby

101

 

MONDAY, JANUARY 15, 1973
MORNING SESSION

 

8:00 - 9:50 a.m.
9:00 - 9:50 a.m.

Registration, Concourse Level Lobby

 

Coffee and Pastry, Concourse Level Lobby

 

10:00 - 10:10 a.m.

10:10 - 10:30 a.m.

10:30 — 10:35 a.m.

10:35 - 11:20 a. m.

11:20 - 11:40 a.m.

11:50 - 1:00 p.m.

GENERAL SESSION, Jefferson East

Opening Remarks
Theodore Cooper, M.D. , Director

National Heart and Lung Institute

Introduction of Keynote Speaker
Robert W. Berliner, M.D.
Deputy Director for Science
National Institutes of Health

Kefliote Address
The Honorable Elliot L. Richardson

Secretary of Health, Education, and Welfare

Acknowledgment and Thanks
Theodore Cooper, M.D.

Introduction of Conference Speaker
W. McFate Smith, M.D.
Regional Health Director, Region ]X
Department of Health, Education, and Welfare

Conference Address: "High Blood Pressure in the U.S. —
An Overview of the Problem and
the Challenge"

Jeremiah Stamler, M.D. , Executive Director
Chicago Health Research Foundation

Floor Discussion
Theodore Cooper, M. D.
LUNC HEON

Speaker
Charles C. Edwards, M.D.
Commissioner
Food and Drug Administration

102

AFTERNOON SESSION

GENERAL SESSION, Jefferson East

1:15 - 2:45 p.m.

Introduction of Resmnders

Theodore Cooper, M. D.

Responders

2:45 - 2:55 p.m.

LABOR:
Leo Perlis
Director
Department of Community Services
AFL-CIO

PRACTICING PHYSICIANS:
Ray W. Gifford, M.D.
Director
Department of Hypertension and Nephrology
Cleveland Clinic

MEDICAL EDUCATION:
J. Willis Hurst, M.D.
Professor and Chairman
Department of Medicine
Emory University

INSURANCE AND OCCUPATIONAL HEALTH:

Leon J. Warshaw, M.D.

Vice President and Chief Medical Director

Equitable Life Assurance Society of the United

States

MEDIA:

Thomas J. Deegan , Jr.

President

Thomas J. Deegan Co. , Inc.

CONSUMER:
Mrs. Earlean Lindsey
Community Organization, Resource Specialist
Mile Square Health Center

C omments

Theodore Cooper, M. D.

103

3:00 - 5:30 p.m.

5:30 p.m.

6:00 - 8:00 p.m.

AFTERNOON SESSION (Continued)

PANEL DISCUSSIONS *

Adams Room

Bancroft Room

Chevy Chase

Room

DuPont Room

Edison Room

Farragut Room

Grant Room

Hamilton Room

Independence

Room

Jackson Room

PANEL 1 4 Health Care Systems and Resources ’
Mitchell Perry, M.D. - Discussion Leader
Bruce Witwer - Recorder

PANEL 2 - Community Education
Gerald H. Payne, M.D. - Discussion Leader
Gerald Wilson — Recorder

PANEL 3 - Community Education
William J. Zukel, M.D. — Discussion Leader
Deanne Knapp, Ph.D. - Recorder

PANEL 4 — Health Care Systems and Resources
Frank Finnerty, Jr. , M.D. - Discussion Leader
Rosalie J. Silverberg - Recorder

PANEL 5 - Community Education
Graham W. Ward - Discussion Leader
Ruth Hegyeli, M.D. - Recorder

PANEL 6 - Professional Education
Namiko Kominami, M.D. - Discussion Leader
Robert Temple, M.D° — Recorder

PANEL 7 — Health Care Systems and Resources
W. McFate Smith, M.D. - Discussion Leader
Spencer Schron — Recorder

PANEL 8 - Professional Education
John H. Moyer Ill, M.D. - Discussion Leader
Martin Greenfield, M.D° - Recorder

PANEL 9 — Professional Education
J. Richard Crout, M.D. - Discussion Leader
Robert Gold - Recorder

PANEL 10 - Health Care Systems and Resources
Harold Margulies, M.D. - Discussion Leader
Margaret Sloan, M.D. - Recorder

Adjournment of Panel Discussions

BUFFET DINNER with Cash Bar Cocktails, Georgetown West

* Coffee and soft drinks available in panel discussion rooms

104

HYPERTENSION INFORMATION AND EDUCATION ADVISORY COMMITTEE

MARSTON, Dr. Robert Q. (Chairman)

Director

National Institutes of Health
Bethesda, Maryland 20014

CHAMBERLAIN, Mrs. Naomi H.
Assistant Professor, Preventive
Medicine and Community Health
School of Medicine and Dentistry
University of Rochester
Rochester, New York 14620

DEEGAN, Mr. Thomas J., Jr.
President

Thomas J. Deegan Company, Inc.
17 Battery Place North

New York, New York 10004

Fl'NNERTY, Dr. Frank A., Jr.
Professor of Medicine

Georgetown University Medical Division
District of Columbia General Hospital
Washington, 13.0. 20003

KOMlNAMI, Dr. Namiko

Straub Medical Research Institute
888 South King Street

Honolulu, Hawaii 96813

MOSES, Dr. Campbell, Jr.
Medical Director

American Heart Association, Inc.
44 East 23rd Street

New York, New York 10010

MOYER, Dr. John H., III

Vice President of Academic Affairs
Hahnemann Medical College and Hospital
230 North Broad Street

Philadelphia, Pennsylvania 19102

PAGE, Dr. Irvine H.

Senior Consultant, Research Division
Cleveland Clinic Foundation

8907 Carnegie Avenue

Cleveland, Ohio 44106

SOKOLOW, Dr. Maurice
Professor of Medicine
Department of Medicine
University of California

Room 573 Moffett Hospital

San Francisco, California 94122

WARD, Mr. Graham W.

Assistant Director for Professional and
Public Relations

Western Pennsylvania Regional Medical
Program

3530 Forbes Avenue

Pittsburgh, Pennsylvania, 15213

EXECUTIVE SECRETARY
John B. Stokes III, M.D..
National Institutes of Health
Building 31 - Room 5A-23
Bethesda, Maryland 20014

105

EX OFFIC IO

EDWARDS, Dr. Charles C. MUSSER, Dr. Marc J.
Commissioner Chief Medical Director

Food and Drug Administration Department of Medicine and Surgery
5600 Fishers Lane Veterans Administration

Rockville, Maryland 20852 Washington, D.C. 20420

SENCER, Dr. David J.
Interim Administrator
Health Services and Mental
Health Administration
5600 Fishers Lane
Rockville, Maryland 20852

106

 

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U.S. DEPARTMENT OF HEALTH, EDUCATION. AND WELFARE
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Bethesda, Md. 20014

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