In 1912, the Chicago physician James Herrick published a seminal paper on the diagnosis of coronary heart disease—following up on the work of two Russian clinicians in Kiev—but only after Herrick used the newly invented electrocardiogram in 1918 to augment the diagnosis was his work taken seriously. This helped launch cardiology as a medical specialty, and it blossomed in the 1920s. White and other practitioners may have mistaken the new understanding of coronary heart disease for the emergence of the disease itself. “Medical diagnosis depends, in large measure, on fashion,” observed the New York heart specialist R. L. Levy in 1932. Between 1920 and 1930, Levy reported, physicians at New York’s Presbyterian Hospital increased their diagnosis of coronary disease by 400 percent, whereas the hospital’s pathology records indicated that the disease incidence remained constant during that period. “It was after the publication of the papers of Herrick,” Levy observed, that “clinicians became more alert in recognizing the disturbances in the coronary circulation and recorded them more frequently.”
Over the next thirty years, recorded cases of coronary-heart-disease fatalities increased dramatically, but this rise—the alleged epidemic—had little to do with increasing incidence of disease. By the 1950s, premature deaths from infectious diseases and nutritional deficiencies had been all but eliminated in the United States, which left more Americans living long enough to die of chronic diseases—in particular, cancer and heart disease. According to the Bureau of the Census, in 1910, out of every thousand men born in America 250 would die of cardiovascular disease, compared with 110 from degenerative diseases, including diabetes and nephritis; 102 from influenza, pneumonia, and bronchitis; 75 from tuberculosis; and 73 from infections and parasites. Cancer was eighth on the list. By 1950, infectious diseases had been subdued, largely thanks to the discovery of antibiotics: male deaths from pneumonia, influenza, and bronchitis had dropped to 33 per thousand; tuberculosis deaths accounted for only 21; infections and parasites 12. Now cancer was second on the list, accounting for 133 deaths per thousand. Cardiovascular disease accounted for 560 per thousand.
Fortune magazine drew the proper conclusion in a 1950 article: “The conquering of infectious diseases has so spectacularly lengthened the life of Western man—from an average life expectancy of only forty-eight years in 1900 to sixty-seven years today—that more people are living longer to succumb to the deeper-seated degenerative or malignant diseases, such as heart disease and cancer….” Sir Maurice Cassidy made a similar point in 1946 about the rising tide of heart-disease deaths in Britain: the number of persons over sixty-five, he explained, the ones most likely to have a heart attack, more than doubled between 1900 and 1937. That heart-attack deaths would more than double with them would be expected.
Another factor militating against the reality of an “epidemic” was an increased likelihood that a death would be classified on a death certificate as coronary heart disease. Here the difficulty of correctly diagnosing cause of death is the crucial point. Most of us probably have some atherosclerotic lesions at this moment, although we may never feel symptoms. Confronted with the remains of someone who expired unexpectedly, medical examiners would likely write “(unexplained) sudden death” on the death certificate. Such a death could well have been caused by atherosclerosis, but, as Levy suggested, physicians often go with the prevailing fashions when deciding on their ultimate diagnosis.
The proper identification of cause on death certificates is determined by the International Classification of Diseases, which has gone through numerous revisions since its introduction in 1893. In 1949, the ICD added a new category for arteriosclerotic heart disease.*4 That made a “great difference,” as was pointed out in a 1957 report by the American Heart Association:
The clinical diagnosis of coronary arterial heart disease dates substantially from the first decade of this century. No one questions the remarkable increase in the reported number of cases of this condition. Undoubtedly the wide use of the electrocardiogram in confirming clinical diagnosis and the inclusion in 1949 of Arteriosclerotic Heart Disease in the International List of Causes of Death play a role in what is often believed to be an actual increased “prevalence” of this disease. Further, in one year, 1948 to 1949, the effect of this revision was to raise coronary disease death rates by about 20 percent for white males and about 35 percent for white females.
In 1965, the ICD added another category for coronary heart disease—ischemic heart disease (IHD). Between 1949 and 1968, the proportion of heart-disease deaths attributed to either of these two new categories rose from 22 percent to 90 percent, while the percentage of deaths attributed to the other types of heart disease dropped from 78 percent to 10 percent. The proportion of deaths classified under all “diseases of the heart” has been steadily dropping since the late 1940s, contrary to the public perception. As a World Health Organization committee said in 2001 about reports of a worldwide “epidemic” of heart disease that followed on the heels of the apparent American epidemic, “much of the apparent increase in [coronary heart disease] mortality may simply be due to improvements in the quality of certification and more accurate diagnosis….”
The second event that almost assuredly contributed to the appearance of an epidemic, specifically the jump in coronary-heart-disease mortality after 1948, is a particularly poignant one. Cardiologists decided it was time they raised public awareness of the disease. In June 1948, the U.S. Congress passed the National Heart Act, which created the National Heart Institute and the National Heart Council. Until then, government funding for heart-disease research had been virtually nonexistent. The administrators of the new heart institute had to lobby Congress for funds, which required educating congressmen on the nature of heart disease. That, in turn, required communicating the message publicly that heart disease was the number-one killer of Americans. By 1949, the National Heart Institute was allocating $9 million to heart-disease research. By 1960, the institute’s annual research budget had increased sixfold.
The message that heart disease is a killer was brought to the public forcefully by the American Heart Association. The association had been founded in 1924 as “a private organization of doctors,” and it remained that way for two decades. In 1945, charitable contributions to the AHA totaled $100,000. That same year, the other fourteen principal health agencies raised $58 million. The National Foundation for Infantile Paralysis alone raised $16.5 million. Under the guidance of Rome Betts, a former fund-raiser for the American Bible Society, AHA administrators set out to compete in raising research funds.
In 1948, the AHA re-established itself as a national volunteer health agency, hired a public-relations agency, and held its first nationwide fund-raising campaign, aided by thousands of volunteers, including Ed Sullivan, Milton Berle, and Maurice Chevalier. The AHA hosted Heart Night at the Copacabana. It organized variety and fashion shows, quiz programs, auctions, and collections at movie theaters and drugstores. The second week in February was proclaimed National Heart Week. AHA volunteers lobbied the press to alert the public to the heart-disease scourge, and mailed off publicity brochures that included news releases, editorials, and entire radio scripts. Newspaper and magazine articles proclaiming heart disease the number-one killer suddenly appeared everywhere. In 1949, the campaign raised nearly $3 million for research. By January 1961, when Ancel Keys appeared on the cover of Time and the AHA officially alerted the nation to the dangers of dietary fat, the association had invested over $35 million in research alone, and coronary heart disease was now widely recognized as the “great epidemic of the twentieth century.”