An epidemiological study of myocardial infarctions in an ItaliandashAmerican community

J. chron. Dis. 1965, Vol. 18, pp. 353-365.

PergamonPress Ltd. Printed in Great Britain

AN EPIDEMIOLOGICAL STUDY OF MYOCARDIAL INFARCTIONS IN AN ITALIAN-AMERICAN COMMUNITY A PRELIMINARY

SOCIOLOGICAL

STUDY

JOHN G. BRUHN, Ph.D.* The Neurocardiology Research Program of the Department of Medicine, and the Biostatistical Unit of the Department of Preventive Medicine and Public Health, University of Oklahoma Medical Center, U.S.A. (Received 5 May 1964)

STRESSis one of the many causal theories of coronary heart disease. One theory pertaining to situational and intra-psychic stress is the notion of the ‘marginal man’ as subject to cultural conflict. CHILD [1] has suggested that the ‘marginal man’ may experience b&cultural conflict as a personal problem unless he chooses one identity or the other. LENSKI’S[2] concept of status crystallization poses the question of the compatibility of role demands on the individual; it implies that the individual who has not achieved ‘crystallization of status’ (educationally, occupationally, and ethnically) is subject to cross-pressures pulling him in opposing directions. Another well-documented general source of stress is that arising from America’s complex, demanding urban way of life, which may be characterized as impersonal, rapidly changing and tension-producing. Stress has been shown to vary in type and degree by socioeconomic groups and in the family patterns of various ethnic groups [3, 41. Studies focusing on ethnic and cultural factors have shown that coronary heart disease is more prevalent among ethnic groups living in America (Negroes, Jews, Italians and Japanese) than those same groups living in their native countries [5, 61. Relatively little work has been done on ethnic differences within one country, although EPSTEINet al. [7] found that Jewish clothing workers in New York City had a coronary rate twice as high as that for Italian clothing workers. STAMLER[8] found that the incidence of coronaries for native-born workers and foremen was three times the rate for foreign-born workers in these occupations. TOOR et al. [9] reports that the Yemenite Jews (Near Eastern) in Israel, who are usually of low economic status, had a lower incidence of coronaries than the Ashkenazim Jews (European) who are economically better off. Background of present study STOUTet al. [IO] in a study of certificates of all deaths attrib<ed to cardiovascular

disease from 1955 to 1961 for five towns in Pennsylvania, found that Roseto, an all *AssistantProfessor of MedicalSociology. This work was supported in full by the PHS Research Grant No. HE-06286-04from the National Heart Institute, Public Health Service. 353

354

JOHN G. BRUHN

Italian-American community, had no recorded deaths from myocardial infarction under 47 years of age. The observed death rate from myocardial infarction was 1.O/ 1000 for males and 0.6/1000 for females. These rates were low compared to the U.S. average death rate from arteriosclerotic heart disease including myocardial infarction (3.59/1000 for males and 2.09/1000 for females). Also, the Rosetan death rate from myocardial infarctions was approximately one-half the rate of each of the four surrounding towns which are predominately non-Italian. These findings precipitated the present investigation to: (1) uncover medical and social factors that might explain the low death rate from myocardial infarctions in Roseto, and (2) determine the existing prevalence of myocardial infarctions in the community. The primary aims of this paper are to: (1) describe the social structure of Roseto from a historical perspective and (2) report preliminary sociological tidings from a epidemiological study which screened the Roseto population for clinical evidence of myocardial infarctions. SOCIAL

STRUCTURE

OF

ROSETO

Brief history of Roseto In the southeastern part of Italy, approximately 30 miles inland from the Adriatic seaport of Bari, lies Roseto, Valfortore, Foggia. The town was called Rosetum by the Romans because of the rose-covered countryside. Extreme poverty and economic injustices, stemming from the monastic control of resources by provincial rulers, had created a stagnant society, despite the scenic beauty. In 1871, letters from Father Luigi Sabetti praising America, stimulated the Italian peasants and skilled workers to seek new opportunities there [ 111. In 1882 the first eleven Rosetans came to New York and were hired to work as laborers in the slate quarries surrounding Bangor, Pennsylvania, a predominately English and Welsh community in existence since 1863. It was in 1887 that Roseto, Pennsylvania, had its origin, known to Rosetans at that time as ‘Little Italy,’ and to the non-Italians in the area, as ‘Italy Town.’ The Italians, who had little or no formal education and were unable to speak English, were treated as slaves by the English and Welsh proprietors for whom many worked for fXty cents a day. The Italians were discriminated against on both ethnic and religious grounds. Segregation of the Italian laborers in barns was common, and their association with the English and Welsh on a social basis was prohibited. Despite their initial economic difficulties in the United States, the Italians were economically scrupulous and soon were able to send for their families and relatives. Unrestricted immigration and inexpensive passage to America soon began to have its effects on the estimated population of 5060 Rosetans in Italy. After overt discrimination subsided in the 1930’s, mole Italians began to move to Bangor because of available land and jobs and the relative closeness to factories in the area. Many were Italians who were born in the United States and had never lived in Roseto, Pennyslvania. However, some Roseto Italians also moved to Bangor. Rosetans describe their fellow townspeople who have left Roseto and have moved to Bangor as people who wanted to become ‘more American’ and/or ‘who thought they were a little better than we were.’ Most immigrants to Roseto were Roman Catholics, but no priest came to Roseto until 1897. However, in 1892 the Presbyterians sent a minister to serve the Italians of New Italy, resulting in the organization of the Presbyterian Church of New Italy with

Epidemiological Study of Myocardial Infarctions in an Italian-American

Community 355

sixty-four members in 1894. This was the first church in Roseto. Shortly thereafter with the arrival of the priests a period of controversy between the priests and ministers ensued, lasting until 1912. The controversies were so bitter that two court cases were instituted between the priests and ministers, one for criminal libel and another to determine the ownership of a strip of land. It was also during this period that the Russellites (Jehovahs Witnesses) came to Roseto and some discontented Presbyterians withdrew from the church to accent this new religion. Today Roseto is a community of 1630. It is located on a heavily forested tract of land, surrounded by slate quarries, on a slope adjoining Bangor, Pennsylvania, with a population of 5766. About 25 per cent of the Bangor population is Italian. ltalians live in most parts of the borough, although the majority live in the Fourth Ward, which is near the Roseto-Bangor boundary. The Fourth Ward is represented in the Bangor municipal government by an Italian councilman. The boundaries of Roseto and Bangor join halfway down the slope and are indistinguishable except for the borough boundary signs. In fact it is said about the Catholic Church, which is on the boundary, that one worships in Roseto and the collection is taken up in Bangor. Today 1208 Rosetans (74 per cent) are members of the Roman Catholic Church although the church also includes 1528 members living in the Bangor area. Almost all parishioners are of Italian heritage. The Presbyterian Church membership is 250 (about 15 per cent of the Rosetan population). Fifty Rosetans (about 3 per cent of the population) are members of the Jehovahs Witnesses, whose total membership in the Roseto area numbers about 350. Most male Rosetans have been and are presently engaged in some type of skilled labor in or near Roseto. Over 75 per cent of the Rosetan women work at least part time as machine operators in the sixteen blouse and shirt mills, which are largely jointly-owned family businesses. Currently there are fewer operational slate quarries in the area, but they are economically lucrative for the owners who employ many Rosetans and Bangorians. Many Jtalians live in Roseto, but work in Bangor and vice versa. Roseto and Bangor Italian Catholics attend the same church and send their children to the only parochial grade and high schools which are in Roseto. Bangor Italians maintain close ties with relatives in Roseto and many participate in Roseto social organizations and the annual religious festival of Mt. Carmel. Bangor Italians are generally accepted by non-Italian Bangorians, as evidenced by the Italians who are members of Bangor social organizations and churches, attend Bangor public schools, are employed in Bangor businesses and industries and have married non-Italians. The Bangor non-Italian views the Bangor Italian as ‘more suave and more American’ than the Rosetans who are viewed as ‘clannish, pushy and enthusiastic.’ An attitude of mutual tolerance, rather than acceptance, exists between Rosetans and non-Italian Bangorians who refer to each other as ‘the people up the hill’ and ‘the people down the hill.’ A series of other boroughs in the Roseto area are of mixed ethnic origin and do not possess distinctive traditions and customs, except for the nearby community of Nazareth, which is predominately German and retains patterns of the Moravian way of life.

356

JOHN G. BRUHN

Social class structure

After observing the informal social structure of Roseto one might easily be misled into assuming the existence of a uniform social class structure. Rosetans mix freely in all but religious affairs. Educationally and occupationally Rosetans might be classified as a lower-class community with middle-class values. Because both husbands and wives work, the average income for most families is between $5000 and $9000 annually. Rosetans are thus materially able to fulfill many of their middle-class aspirations. Almost all Rosetans own their own homes and their affluence is notable by their late model cars, color TV sets, modernly furnished homes and the large number of young Rosetans who attend college. The formal social class structure, however, is more circumscribed. There is a small elite ‘wealthy’ group composed of three or four families who derive their incomes from several business ventures (textiles, slate, and investments). This group, none of whom are college-educated, have risen to a position of economic power. These elite associate in social cliques with other large blouse mill and slate quarry owners and physicians from Bangor and surrounding areas. Although these elite are members of Roseto community clubs and support them financially, they are not active members. Since many blouse mills are held in partnership or family owned, some overlapping in the social structure occurs such as in social situations where the wealthy members of a clan may be obligated to invite the less wealthy merely on the basis of their familial ties. The small independent merchants and skilled laborers do not have the closed, social cliques of the entrepreneurs. They commonly gather in one of the community clubs for their entertainment, which consists frequently of a spaghetti dinner and wine followed by beer and poker or ‘boss’. The only occupational associations of the laborers are the labor unions. Few, if any, Rosetans could be called ‘poor’, although some families are noted to live in less desirable homes than are characteristic of most Rosetans. There is, however, no distinctive geographic isolation of these families. No poverty, as such, exists in Roseto, and community groups which provide for the needy have been notably inactive. Ethnic social structure

There is a parallel ethnic structuring in Roseto, distinct from the social class structure which was based primarily on wealth. The ethnic structure is based on: (1) when one’s ancestors came to Roseto; (2) the geographic origin of one’s ancestors in Italy, and (3) whether or not one is of Italian extraction. The founders and descendants of the founders of Roseto, Pennsylvania, enjoy very high status among Rosetans, independent of wealth. Most Rosetans trace their origin to Roseto, Italy, although they readily point out those families who came from other parts of Italy. The few Rosetans who came from Naples and Sicily relate that almost a generation passed before they were fully accepted into the in-group. Recent immigrants also experience similar difficulty in acceptance. Time, conformity to Rosetan customs and values, and learning the English language are prerequisites of acceptance into the community. ‘Outsiders’ (non-Italians) receive gracious Italian hospitality, but only three non-Italian families live in Roseto. Few Rosetans who have married outside their ethnic group live in Roseto; most have moved to Bangor or to other areas.

Epidemiological Study of Myocardial Infarctions in an Italian-American Community 357 In summary, Roseto is a community whose inhabitants share a common history and ancestry. It has contained itself as a separate ethnic enclave since its founding. It is a community striving to retain its traditions, dietary habits and closely-knit families, while selectively incorporating the educational, occupational and income values of the larger society which are well imbued in the present third-generation Rosetans. Many young Rosetans leave the community to enhance their education and ultimately find jobs elsewhere as the only available jobs in Roseto are those involving skilled or semiskilled work. Thus, although the total population of Roseto has remained relatively stable, it is increasingly becoming a community of older persons. RESEARCH METHODS In December 1962 and the summers of 1963 and 1964, a group of Oklahoma University Medical School investigators established a community medical clinic in Roseto. The clinics were publicized through the mass media as health clinics offering free physical and laboratory examinations to all Rosetans over age 21 and their relatives living in Bangor OI elsewhere in the United States. The purpose of the study, namely, to screen the Roseto population for evidence of myocardial infarctions, was made known to the community residents. Electrocardiographic evidence was the sole criterion by which physicians on the team arrived at a diagnosis of myocardial infarction. Respondents who had a history of a myocardial infarction, but did not show evidence of such on their electrocardiograms, were categorized as ‘questionable’ and not included in the prevalence computations. A total of 1071 Italianas volunteered to be examined in the three clinics: 494 Rosetans, 390 Bangorians, and 187 who lived elsewhere. Sociological interviews were introduced in the clinic conducted in the summer of 1963. It was only feasible to interview six people a day of the 30-40 respondents participating in this daily clinic. Therefore, with the exception of the patients with diagnosed myocardial infarctions, the interviewees were chosen at random and thus a total sample of 207 was obtained. Of the 207 interviewees, 134 were Rosetans, 42 were Bangorians, and 31 lived elsewhere. All interviewees in the sociological study were Italian. The main focus of the unstructured sociological interviews was on the faniily as a potential agent for stress-producing situations. We were interested in both the nature of family stress situations and the patterns taken toward their resolution. Other information elicited regarding family relationships included : marital adjustment, religiosity, educational and occupational mobility, income, membership and participation in community organizations, birthplace of family members (whether Roseto, Italy; Roseto, Pennsylvania; or elsewhere in the U.S.) and geographic and residential mobility. Additional information regarding marital adjustment and religiosity was obtained by means of a structured questionnaire, which was completed in the clinic by the married respondents. The marital adjustment scale was composed of 12 items selected from a factor analysis study of 20 items measuring marital adjustment, conducted by LOCKEand WILLIAMSON [12]. The religiosity scale, which was essentially a religious conservatism scale stressing dogma and supernaturalism, was composed of 13 items from a scale used by MARTIN and WE~TIE [13]. These scales were analyzed using analysis of variance for independent samples, completely randomized design.

358

JOHN G.BRUHN

RESULTS

AND

DISCUSSION

Prevalence of myocardial infarctions Thirty of the 1071 Italian respondents

in the total clinic sample showed electrocardiographic evidence of a myocardial infarction. Eighteen of the people with infarctions were interviewed and included in the sociological analyses, Table 1 shows the total prevalence of myocardial infarctions by age groups for Italian males from Roseto, Bangor and out-of-town (age adjusted rates of 45.2; 53.7 and 74.3 per thousand respectively). Although the rates of these groups do not differ markedly, it Is noted that the prevalence rates tend to increase as one moves away from the community of Roseto. Also, the table shows a strikingly lower rate for Rosetan males compared to Bangor males and males living elsewhere aged 65 and over (rates of 27 .O; 95.2 and 166.7 respectively). This finding corresponds with the observation that older Roseto Italians have a lower death rate from myocardial infarctions. The fact that older Rosetans are retained in the community and are given community and familial support in their later years possibly plays an important part in this finding. TABLE 1. PREVALENCEPER 1000 OF MYOCARDIALINFARCTION(DEFINITEAND PROBABLEBY ECG)

ITALIAN MALESIN

Age

group

<35 35-44 45-54 55-64 65> Age adjusted

prevalence

ROSETO No. Myocardial in infnrction sample No. Rate/1000

FOR

CLINIC SAMPLE BANGOR

No. in sample

ELSEWHERE

Myocardial infarction No.

Rate/l000

No. sgple

Myocardial infmtion No.

Rate/l000

48

0

0

41

0

0

32

51 53 38 37

1 2 6 1

19.6 37.7 157.9 27.0

51 51 28 21

1 3 3 2

19.6 58.8 107.1 95.2

24 22 15 6

0” ; 1

0” 90.9 133.3 166.7

227

10

45.2

192

9

99

5

74.3

53.7

Table 2 show the total prevalence of myocardial infarctions by age groups for Italian females from Roseto, Bangor and out-of-town (age adjusted rates of 13.5; 10.9 and 0 per thousand respectively). These rates are notably lowei than those TABLET. PREvAtENCEPER

1000 OFhfYOCARDIALINFARCTION(DEFINITE AND PROBABLE BY ECG)FOR ITALIAN FWALESM CLINIC SAMPLE ROSETO

No.

Age group

sgpIe

BANGOR

Myocardial infarction No. Rate/1000

No.

ELSEWHERE

Myocardial infarction

szple

No.

Rate/1000

No.

Myocardial infarction

szple

No.

Rate/1000

<35

50

0

0

30

0

0

35-44 45-54 55-64 65> Age adjusted

61 83 48 25

0 1 3 0

0 12.0 62.5 0

53 67 23 25

0 1 1 0

0 14.9 43.5 0

19 32 19 12 6

0 0 0 0 0

0 0 0 0 0

267

4

13.5

198

2

10.9

88

0

0

prevalence

Epidemiological

Study of Myocardial

Infarctions

in an Balian-American

Community

359

observed among the men. Because of the paucrty of infarctions among Italian women in the sample groups no generalizations are warranted at this time, The prevalence rates of coronary heart disease found in the Roseto study could not be meaningfully compared with the Framingham, Mass., study [14] and the study of EPSTEINet al. [8] of Italian clothing workers in New York City because diagnostic criteria differed between the studies. Social characteristics of sociological sample

First we determined how representative the Roseto interviewees were of their community. Table 3 shows that the Roseto sample was fairly representative of the Roseto population by sex, and generally representative by age, except the sample was over-representative of males aged 55-64 years. TABLE 3. CIJMPARIWNOF TOTAL ROSETO POPULATIONAND SOCIOLOOICAL SAMPLEBY SEX AND AGE Roseto population* 1960 Age group

21-24 25-34 354I 45-54 55-64 65+

Male

Roseto sociological samplet 1963

Females No. %

No.

%

502

47

577

30 109 121 102 69 71

2; 24 20 14 14

33 118 143 145 63 75

No.

%

Female No.

%

53

60

45

74

55

6 20 25 25 11 13

2 8 9 12 17 12

3 13 15 20 28 20

1: 14 21 12 10

2; 19 29 15 14

Male

*1960 U.S. Census=1630. Since the study included only persons over age 21, the age group 21-24 above is an estimate of the census age group 15-24. tExcludes 42 Bangor and 31 out-of-town respondents.

Table 4 shows the subjects in the sociological sample by sex, age, education and social class. Among the persons without recognized myocardial infarctions, it was found that the out-of-towners were significantly different from the Rosetans and Bangorians (P < 0.01). They were younger, had achieved more education and were predominately from the middle and upper social classes (I-II-III). The mean age of persons with recognized myocardial infarctions was significantly different from persons without recognized myocardial infarctions (PC 0.01). The two groups were also significantly different in education (PC 0.01). The persons with recognized myocardial infarctions did not differ significantly from persons without recognized myocardial infarctions on social class. Of all respondents, 78 per cent were married, 10 per cent were single, 9 per cent were widowed and 3 per cent were remarried. Of the respondents 73 per cent were Roman Catholics, 25 per cent Protestant, and 2 per cent had no religious affiliation. Regarding birthplace, 66 per cent of all respondents were born in Roseto, Pa., 12 per cent were born in Italy and 22 per cent were born elsewhere in the United States. The respondents with recognized myocardial infarctions did not differ significantly from the respondents without recognized myocardial infarctions on these variables.

360

JOHN G. BRUHN TABLE 4.

Suat~crs IN SOCIOLOGICAL SAMPLEBYSEX,AGE, EDUCATION AND SOCIALCLASS

Mean age

Sex

Mean years of education

Social class (M & F)*

Subject groups (n=207) Persons without recognized myocardial infarctions (n= 189) Roseto Bangor Out-of-town

M

F

52 30 23

70 9 5

Overall mean both sexes Persons with recognized myocardial infarctions (n=l8) Roseto Bangor Out-of-town

49.3 44.9 40.5

47.0 52.3 37.8

M

F

9.5 9.4 14.0 ey-

8.8 7.4 11.0

46y.5

8 3 3

4 0 0

119

65.1 66.0 50.0

I-II-III

IV-V

32

90 30 10

3 0 0

9 3 3

62

145

9.5

60.7 -

9.2 5.6

5.5 -

6i.7

Overall mean both sexes Total

MF

88

*Using Hollingshead’s Index of Social Position based on the occupation and education of the head of the household. Classes 1-II-III=‘white collar,’ Classes IV-V=‘blue collar.’

Because of the small number of people with recognized myocardial infarctions, these people were combined to form a patient group. This group in turn was compared with Rosetans, Bangorians, and out-of-towners without myocardial infarctions. Marital adjustment and religiosity

Table 5 presents a summary of the analysis of variance of the marital adjustment scale. The Roseto, Bangor, out-of-town and patient groups did not differ significantly in their mean marital adjustment scores. These findings seem to indicate that Rosetans, living in a family-centered, closely-knit community are not any better maritally adjusted than the Italians living in Bangor or elsewhere in the U.S. The persons with recognized myocardial infarctions were not distinctive by their marital adjustment TABLE 5. SUMMARY

Group? Bangor (n = 35) Patients (n=9) Roseto (n=98) Out-of-town (n=20)

OF ANALYSIS OF VARIANCE FOR MARITALADJUSTMENT SCALEIN SOCIOLOGICAL SAMPLE* Means$ 35.8 40.2 41.4 43.5

Adjusted means

F

P

35.6 40.5 41.2 43.6

2.44

ns.

*Covariance adjustment for age and education. tNumbers exclude uumarried respondents and those not completing this section of the questionnaire. #Scale limits O-12, the lower the score the more compatible the marital situation.

Epidemiological

Study of Myocardial

Infarctions

in an Italian-American

Community

361

scores. These results do not mean that the respondents in these groups were all happily married. Although only 2 per cent of the 1071 respondents were separated or divorced, there were other indications of unhappy marriages which may have held together because of consequential religious sanctions. However, when separation or divorce did occur it was noted that the respective parties frequently returned to live with their parental families where moral and financial support were forthcoming. Table 6 shows the summary of the analysis of variance of the religiosity scale. The Roseto, Bangor, out-of-town and patient groups differed significantly on this scale. Duncan’s New Multiple Range test showed that the Roseto and patient groups had significantly lower (more conservative) religiosity scores than the Bangor and out-oftown groups (P< 0.05). There were no differences between the religiosity scores of Protestants and Catholics*. TABLE6.

SUMMARYOF ANALYSIS OF VARIANCE FORRELIGIOSITY SCALEIN SOCIOLOGICAL SAMPLE*

Group

Means?

Adjusted means

F

P

Roseto (n =98) Patients (n=9) Bangor (n = 35) Out-of-town (n=20)

42.4 42.4 52.0 52.2

42.6 42.8 52.4 50.1

7.63

0.001

*Covariance adjustment for age and education. tScale limits O-13, the lower the score the greater the religiosity.

Education and prevailing religious norms of one’s environment are both important in interpreting these results. Since it was found that religiosity decreases with increasing education, it is not surprising that the out-of-towners, who had achieved more education than the other groups, should have higher (less conservative) religiosity scores. Also, the majority of Rosetans and patients, who were born in Roseto, Pa., had been subject to the same community religious norms throughout their lives. In contrast, about 50 per cent of the Bangor and out-of-town Italians were not born in Roseto, Pa., and thus were not subject to group norms where their religious lives and practices could be scrutinized as they would be if they lived in Roseto. KING and FUNKENSTEIN, [15] found that subjects who responded to acute stress with a norepinephrine-like cardiovascular response were individuals who had conservative religious attitudes and beliefs and came from families where church attendance was regular. Subjects who responded with an epinephrine-like response held more liberal religious views and came from families where church attendance was infrequent. This latter finding may apply to the out-of-towners in the present study, who have a higher prevalence of myocardial infarctions, have less conservative religious beliefs and also, by their geographical separation, lack the ethnic and social bonds which Rosetans share. Educational and occupational mobility

Educational and occupational aspirations have been shown to be stress-related factors, since they are essential ingredients of upward social mobility [16-191. *Kendall’s rank correlation scores were correlated.

coefficient was not significant when religiosity and marital adjustment

362

JOHN G. BRUHN

Significantly more of the Bangorians, out-of-towners and patients were occupationally upwardly mobile from their parents compared to the Rosetans. The Rosetans, like their parents, were engaged primarily in ‘blue collar’ occupations such as machine operators, pressers, construction, railroad or quarry workers OI truck drivets, while more of the Bangorians and out of towners were working in supervisory and sales positions, or as small business owners, technicians or professionals. There were no particular occupational types that characterized the patients. There were no statistically significant differences among the groups on educational mobility, the majority of all respondents were educationally upwardly mobile from their parents. The out-of-towners tended to be the most upwardly mobile, followed by the Bangorians, and lastly by Rosetans and patients who were similar. The greater mobility of the out-of-towners is understandable in that they are significantly younger than the Rosetans, Bangorians and patients. There were no significant differences between the groups on income, despite the higher education and higher salaried jobs of the out-of-towners. This is due to the fact that the majority of both husbands and wives work in Roseto, enabling them to double their family incomes and thus attain incomes similar to the out-of-towners. Having two breadwinners in Rosetan households with the consequential sharing of financial and work stresses, is probably a potent factor operating against the deleterious effects of mobility and striving, common in American middle class society. Organizational membership

Significantly more Rosetans were members and active participants in community social organizations than were Bangorians, out-of-towners and patients. More Rosetan men than women were members of community organizations. This is because most of the organizations such as the Marconi Club, Rod and Gun Club, American Legion and Fire Company provide for male-centered activities where there is bantering, joking, bragging and demonstration of individual skill and superiority in competitive card playing. Rosetan women are members of the auxiliaries of these organizations, which meet less frequently. The extra-curricular activities of the women center around informal cliques. The important point is that Rosetan social life provides for companionship and belongingness and also opportunities for individuality. Thus, the Rosetan, like a rubber band, can be drawn back and forth between his closely-knit family and more informal groups usually composed of individuals of similar ethnic, educational and occupational backgrounds. This is also applicable to Bangor Italians, for even though their social contacts include confrontations with non-Italians, their cultural marginality enables them to retreat to the safety of their ethnic bonds. The out-of-towners, who have moved into the mainstreams of American society must conform to a different set of values regarding companionship, belongingness and expressions of individuality or be forced to retreat to their immediate families or unto themselves. Geographical and residential mobility

Very few Italians move into Roseto, rather Rosetans move to Bangor or other areas. Since most people who leave Roseto do so to enhance their education or occupation, which is encouraged, and Rosetans who marry non-Italians also usually

Epidemiological Study of Myocardial Infarctions in an Italian-American

Community 363

do not return to live in Roseto, Rosetan culture does not undergo a constant process of change and accommodation. There is practically no residential mobility in Roseto, although some Rosetans are building fashionable homes on and outside the borough boundary; however, attempts are being made to incorporate these people into the Roseto borough. Thus, the physical stability of the Rosetans permits them to retain ethnic and cultural continuity.

Mutual support in Roseto

When crises or stresses occur in Roseto they are largely coped with jointly by family members with support from relatives and friends. When a death occurs, interfamilial differences are forgotten and the bereaved receive food and money from relatives and friends, who many times temporarily assume responsibilities for the care of the children of the bereaved. When family tinancial problems arise relatives and friends rally to their aid and in cases of abrupt, extreme financial loss the community assumes the responsibility for helping the family. Personal and family problems are usually worked out with the help of other clan members and often the priest. The elderly are cared for in the homes of their kin and are usually only institutionalized when physical and mental deterioration prohibit further home care. In cases of illegitimacy, divorce or mental retardation, the family retains the individual in the home. It was noted that the responsibility for the majority of family problems in Roseto fell upon, or was assumed by, the unmarried females or other family members with no children. A number of single women in the community have assumed the role of ‘martyr’ for their families and have undertaken the primary responsibility for caring for their elderly parents, or an illegitimate or mentally retarded child. Usually the ‘martyr’ was the older and/or ‘strongest’ member of the family. A common theme elicited from these ‘martyrs’ was that (1) close family ties, (2) security derived from their religion, and (3) knowing that the respected people in the community were on their side, had been essential in coping with their family crises. “When you have these things,” one respondent said, “then you can carry your cross.” The preliminary nature of this study does not provide sufficient evidence to permit a detailed characterization of the persons with myocardial infarctions. However, some observations have been made and offer hypotheses for continuing studies of the persons with infarctions. The patients generally presented a different theme for dealing with the crises in their lives than the theme outlined previously for Rosetans. The majority of the patients stated that they kept their problems to themselves; they ‘paddled their own canoes.’ In addition, 50 per cent of the patients had only superficial religious ties. It is possible that these people may be isolates in their community and thus lack communal support when needed. As one respondent said, “It is possible to be here in Roseto invisibly-outside the sphere of communication and activity.” It might be hypothesized that the persons with infarctions were alienated from or had rejected their primary groups such as the family, religion and peer group which provide mechanisms for dealing with situations which threaten the individual. Thus, the persons with infarctions might lack the support or ‘cushion’ which these groups provide when certain threats arise such as death, illness or uncertainties surrounding one’s job or employment, which are outside the sphere of individual control.

364

JOHN G. BRUHN SUMMARY

This paper reported some sociological findings of a preliminary study of myocardial infarctions in Roseto, an Italian-American community in Pennsylvania. A medical clinic was established in Roseto in December 1962 and the summers of 1963 and 1964 for Rosetans and their relatives living in nearby Bangor or elsewhere in the U.S. to undergo extensive medical examinations foi evidence of heart disease. Of the 1071 Italian volunteers, 30 showed electrocardiographic evideace of a myocardial infarction. Comparisons of the prevalence rates of myocardial infarctions for Rosetan Bangorian and out of-town males showed that as one moved away from the community of Roseto the prevalence rates tended to increase. Also older Rosetan males had a lower prevalence of myocardial infarctions than Bangor and out-of-town males 65 years and ovei. Females had lower rates of myoca.rdial mfarctions than males in all three groups. There were too few cases of Italian females with infarctions to make valid comparisons between Rosetan, Bangorian and out-of-town prevalence rates. Of the clinic volunteers, 207 persons, including 18 of the persons with diagnosed myocardial infarctions, were seen for sociological interviews. Comparisons of the Roseto, Bangor and out-of-town Italians by sex, age, education and social class showed that more of the out-of-towners were younger, were from the middle or upper social classes and had achieved more education than the Rosetans and Bangorians. The persons with recognized myocardial infarctions were significantly older, mean age 61.7, compared to the mean age of persons without recognized myocardial infarctions, 46.5 years. The Rosetans, Bangorians, out-of-towners and patients did not differ significantly from each other in their mean marital adjustment scores. The Rosetans and patients had significantly lower (more conservative) religiosity scores compared to the Bangorians and out-of-towners. The out-of-towners, Bangorians and patients were more occupationally upwardly mobile from their parents than were the Rosetans. The groups did not differ greatly on educational mobility, but the out-of-towners tended to be the most educationally upwardly mobile followed by the Bangorians, Rosetans and patients. All groups tended to have similar family incomes. This is attributable to the fact that both Rosetan husbands and wives work, thus doubling their family incomes and matching the incomes of the out-of-towners. A brief history and description of the Roseto social structure was outlined, especially with respect to the pervasiveness of mutual support among Rosetans in virtually all activities. The role of mutual support in coping with various types of life crises was discussed. This paper presented only preliminary steps of an investigation of myocardial infarctions in an Italian-American community. Several further areas of research are being developed in this continuing study. First a more intensive study and follow-up of currently known people with myocardial infarctions and their families is being undertaken as well as continued research with the entire original 1963 sociological sample. This should enable us to document medical and sociological changes among persons identified as having had a myocardial infarction, and in addition, among those who subsequently develop the disease. This latter possibility can be invaluable in its possibilities for uncovering predictive factors in the epidemiology of myocardial infarctions. Second, a comparison of the results of a study of Bangor, Pennsylvania, undertaken in the summer of 1964, will be made with the findings obtained in Roseto.

Epidemiological’

Study of Myocardial

Infarctions

in an Italian-American

Community

365

This second area of research should shed more light on the relevance of social and cultural factors by comparing two adjacent, ethnically different communities with differing death rates from myocardial infarctions. Acknowledgements-I am indebted to EDWARD N. BRANDT,Jr., M.D., Ph.D. of the University of Oklahoma Biostatistical Unit and Medical Research Computer Center for his co-operation in the data analysis. I am grateful to A.~~KEK. BASUand JOHN T. PATTERSON for their assistance in the data collection. REFERENCES Ztalian or American? The Second Generation in Conflict, Yale University Press, New Haven, 1953. LENSKI,G. E.: Status crystallization: a non-vertical dimension of social status, Amer. sot. Rev. 19,4,1954. HOLLMGSHEAD,A. B. and REDLICH,F. C. : Social CIass and Mental ZlIness. Wiley, New York, 1958. MYERS,J. K. and ROBERTS,B. H.: Family and Class Dynamics in Mental Illness. Wiley, New York, 1959. KEYS, A. : The risk of coronary heart disease, Circulation 23,805,1961. MILLER, D. C., STARE F. J., WHITE, P. D. and GORDON, J. E.: The community problem in coronary heart disease, Amer. J. med. Sci. X32,3,1956. EPSTEM, F. H., BOAS, E. P. and SIMPSON,R.: The epidemiology of atherosclerosis among a random sample of clothing workers of different ethnic origins in New York City, J. chron. Dis. 5, 300, 1957. STAMLER,J. : Prevalence and incidence of coronary heart disease in strata of the labor force of a Chicago industrial corporation, J. chron. Dis. 11,4,1960. TOOR, M., KATCHALSKY,A., AGMON,J. and ALLALOUF,D.: Atherosclerosis and related factors in immigrants to Israel, Circulation 12,265,1960. STOUT, C , MORROW,J , BRANDT,E. and WOLF, S.: Unusually low incidence of death from myocardial infarction in an Italian-American community in Pennsylvania, J. Amer. med. Ass. 188,845,1964. BASER,R.: History of Roseto, Pa.: 1882-1952. Tan&la Printing Co., Easton, Pa., 1952. LOCKE,H. J. and WILLIAMSON,R. C.: Marital adjustment: a factor analysis study, Amer. sot. Rev. 23,562, 1958. MARTIN,J. G. and WESTIE,F. R. : The tolerant personality, Amer. sot. Rev. 24,521, 1959. DAWBER,T. R., MOORE,F. E. and MANN G. V.: Coronary heart disease in the Framingham study, Amer. J.publ. Hlrh 4,4, 1957. KING, S. H. and FUNKENSTEM,D. H.: Religious practice and cardiovascular reactions during stress, J. abnorm. sot. Psychol. 55,135, 1957. DUNBAR,F. : Psychosomatic Diagnosis. Hoeber, New York, 1948. HAMMARSTEN, J., CATHEY,C., REDMONT,R. and WOLF, S.: Serum cholesterol, diet and stress in patients with coronary artery disease, J. clin. Invest. 36,897,1957. RUZ~~EKH. I. and ZOHMAN B. L.: Relative significance of heredity, diet and occupational stress in coronary heart disease of young adults, Amer. J. med. Sci. 235,266, 1958. FRIEDMANM. and ROSENMAN,R. H.: Association of specific overt behavior pattern with blood and cardiovascular tindings, J. Amer. med. Ass. 169,1286,1959.

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