- Email: [email protected]
Ernst Wynder and preventive medicine
Preventive Medicine 43 (2006) 236 – 237 www.elsevier.com/locate/ypmed
Ernst Wynder and preventive medicine Lewis H. Kuller ⁎ Graduate School of Public Health, Bellefield Professional Building, Room 550, 130 North Bellefield Avenue, Pittsburgh, PA 15213, USA Available online 25 September 2006
The relationship of cigarette smoking to disease was still a contentious issue for those of us who trained in medicine and epidemiology in the 1950s and early 1960s. In the 1950s in medical school, smoking was prevalent among both faculty and students. Smoker's cough was a “benign” problem. Chronic pulmonary diseases, such as emphysema and chronic bronchitis, were not considered to be related to cigarette smoking and were “unusual” diseases. The likelihood that smoking caused lung cancer or coronary heart disease (CHD) was downplayed by many of the faculty in medical school. By the time I got to the School of Public Health at Johns Hopkins University in 1962–1963, Dr. Wynder's paper in the Journal of the American Medical Association on smoking and lung cancer and subsequent papers by Levin et al. (1950) and Doll and Hill (1950) had dramatically changed the landscape. The paper by Wynder and Graham (1950) on smoking and lung cancer had become the basis for the rapidly growing case control studies in chronic disease epidemiology, especially cancer epidemiology. Smoking was now accepted as the primary cause of lung cancer and rates of cigarette smoking among my colleagues and faculty had dropped dramatically within a few years. I first got to know Dr. Wynder during the 1960s, when I studied the relationship of cigarette smoking to sudden cardiac death. His work in identifying the specific chemicals in cigarette smoke and how that might be related to various diseases was of critical importance in trying to understand the relationship between cigarette smoking and cardiovascular disease (CVD), especially sudden death. It is hard to believe now but in the 1960s, 70–80% of all of the sudden cardiac deaths in men were occurring among cigarette smokers. There is little question that the substantial decrease in cigarette smoking contributed greatly to the subsequent decline in first event sudden cardiac deaths out of the hospital, especially in young and middle-aged men.
⁎ Fax: +1 412 383 1956. E-mail address: [email protected]. 0091-7435/$ - see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.ypmed.2006.08.003
Dr. Wynder was a very unique investigator. First, he had developed one of the few and perhaps first centers with a primary emphasis on preventive medicine. The American Health Foundation and the Mahoney Institute for Health Maintenance in New York City were clearly unique facilities. Second, he had an unusual commitment to the combining and understanding of biology and pathophysiology of risk factors and disease as the basis for preventive action. It was his understanding of chronic disease pathophysiology, epidemiology, and public health that made him so unique. For example, the major criticism of the smoking and disease relationship was the lack of the identification of specific chemicals in tobacco smoke that caused disease. Many investigators, in some of our most outstanding institutions, argued that it was the psychology or the selection for cigarette smoking that was associated with the disease rather than smoking being in the causal pathway. Dr. Wynder's work at the American Health Foundation was critical in identifying specific chemical components in tobacco smoke that contributed to disease. Dr. Wynder and the American Health Foundation played, I think, the key role in developing the linkages between epidemiology and the study of carcinogenesis which is continuing to evolve to the present day. Tobacco smoking, he showed, was not just the inhalation of hot air. Perhaps some of his sharpest critics were exhaling a lot of hot air. Dr. Wynder played a major role in efforts to link environmental tobacco smoke to illness among non-smokers. His group evaluated the differences between side-stream and mainstream tobacco smoke and technology to measure exposure of non-cigarette smokers to the effects of cigarette smokers, such as the measure of cotinine—a nicotine byproduct in urine. His emphasis on environmental tobacco smoke was an important stimulus for our study of “passive smoking” and CHD in the Multiple Risk Factor Intervention Trial (MRFIT) participants. It was not easy to change Dr. Wynder's opinion. Powerful lobbying groups continued to raise serious doubts about the adverse effects of tobacco smoking and especially second-hand or
L.H. Kuller / Preventive Medicine 43 (2006) 236–237
environmental tobacco smoke. Some of the major tobacco companies continued their efforts over these years to convince the public and especially the politicians in Washington that cigarette smoking was not a hazard. Many of us trained in academic medicine and public health had little stomach to battle the powerful tobacco lobby. Not Dr. Wynder. We were amazed to see how he was able to marshal powerful voices that, to this day, have contributed to the continued efforts to eliminate tobacco smoking. Students in public health are now trained in community organization, participatory research, and the need to increase social capital for public health. I strongly suggest that they carefully review the accomplishments of Dr. Wynder and especially the efforts of the American Health Foundation as a nidus for preventive medicine in the United States. His ability to raise social capital for public health and preventive medicine and the American Health Foundation was legion. Participatory research and programs were relatively simple. Dr. Wynder led the charge, got everybody in sight to participate, and those who didn't better get out of his way. In the early 1980s, I served on the Board of Scientific Counselors of the National Cancer Institute (NCI) Division of Cancer Prevention and Control under the able leadership of Dr. Peter Greenwald and Dr. Joe Cullen. Peter had selected a group of primarily cardiovascular epidemiologists and preventive medicine specialists for the board in order to strengthen the prevention agenda. Dr. Wynder's efforts with the board were a major component of the efforts to enhance preventive medicine research at the NCI. Dr. Wynder had a very strong interest in the interrelationship of diet to cancer. I think he felt very strongly that dietary factors and cigarette smoking were the primary determinants of cancer and that much cancer in the country could be reduced or eliminated by aggressive approaches to reducing cigarette smoking and changing the American diet. He was interested both in the addition of various nutrients, such as vitamins and minerals, and in a low fat diet, increased fiber, and fruits and vegetables. Dr. Wynder proposed in the 1980s that a secondary prevention trial to reduce recurrent breast cancer among treated breast cancer was an important issue. He persevered with his efforts to get a diet-breast cancer trial under way for many years, lobbying our committee, NCI Directors, and Congress. His efforts were ultimately successful, and the trial was finally begun (Chlebowski et al., 1993). The Women's Intervention Nutrition Study (WINS) began and finally in 2005–2006 the initial preliminary positive results have been reported at the American Society of Clinical Oncology by Chlebowski, Blackburn, Elashoff, et al. Dr. Wynder's concern about the importance of nutrition resulted not only in his commitment to do good prevention programs and clinical trials but also to develop a nutrition laboratory science program at the American Health Foundation, an important model for good epidemiology–nutrition research. Dr. Wynder “convinced” me to join the Editorial Board of Preventive Medicine. He had established the journal to enhance research and prevention in practice and theory of preventive medicine. During its early years, it was the official Journal of
237
the American Society of Preventive Oncology. Being a member of the Editorial Board was a unique experience. Dr. Wynder had us meet in the offices of the American Health Foundation in the Ford Foundation Building in New York City overlooking the East River. Epidemiologists are used to working in limited space and facilities. The magnificent offices of the American Health Foundation dedicated to preventive research and community prevention programs was an eye-opening experience. Dr. Wynder had raised the esteem of preventive medicine to new heights, not only by being in the upper floor of the building, but also by making people appreciate that preventive medicine was important. The board would meet for several hours. Dr. Wynder would come in, tell us what to do, and convince us of the importance of the journal, the need to educate both the medical and the lay communities about the importance of preventive medicine. He would tell us how great a job we were doing but that we needed to do better. We should make the journal more effective and use the journal to stimulate preventive medicine practice. He would then take us on a tour of the facilities, make certain to introduce us to the new and promising cadre of investigators who were always doing things that would revolutionize preventive medicine and enhance public health. You left the Ford Foundation Building and the American Health Foundation having received a very heavy dose of enthusiasm for preventive medicine from Dr. Wynder. Hopefully the therapy could last you for 6 months to a year, until the next meeting where he, again, would revive your spirits, convince you that preventive medicine was really important and that you were a member of his flock on your way to raise the banner of preventive medicine and conquer diseases. Dr. Wynder could make anyone a believer in preventive medicine. He combined an uncanny commitment to preventive medicine with brilliance in epidemiology and understanding of the mechanisms and pathophysiology of disease in order to improve health. Most of all, perhaps he was unique in our field by actually succeeding in obtaining “social capital” and recognition for preventive research. Dr. Ernst Wynder was a very strong advocate for preventive medicine. He successfully combined basic mechanistic laboratory and epidemiology approaches to the study of the etiology and prevention of chronic diseases. Perhaps more than anyone else, he was able to attract financial and political support for preventive medicine. References Chlebowski, R.T., Blackburn, G.L., Buzzard, I.M., et al., 1993. Adherence to a dietary fat intake reduction program in postmenopausal women receiving therapy for early breast cancer. The Women's Intervention Nutrition Study. J. Clin. Oncol. 11, 2072–2080. Doll, R., Hill, A.B., 1950. Smoking and carcinoma of the lung: preliminary report. Br. Med. J. 2, 739–748. Levin, M.L., Goldstein, H., Gerhardt, P.R., 1950. Cancer and tobacco smoking: a preliminary report. JAMA 143, 336–338. Wynder, E.L., Graham, E.A., 1950. Tobacco smoking as a possible etiologic factor in bronchiogenic carcinoma. A study of six hundred and eighty-four proved cases. JAMA 143, 329–336.
Ernst Wynder and preventive medicine Lewis H. Kuller ⁎ Graduate School of Public Health, Bellefield Professional Building, Room 550, 130 North Bellefield Avenue, Pittsburgh, PA 15213, USA Available online 25 September 2006
The relationship of cigarette smoking to disease was still a contentious issue for those of us who trained in medicine and epidemiology in the 1950s and early 1960s. In the 1950s in medical school, smoking was prevalent among both faculty and students. Smoker's cough was a “benign” problem. Chronic pulmonary diseases, such as emphysema and chronic bronchitis, were not considered to be related to cigarette smoking and were “unusual” diseases. The likelihood that smoking caused lung cancer or coronary heart disease (CHD) was downplayed by many of the faculty in medical school. By the time I got to the School of Public Health at Johns Hopkins University in 1962–1963, Dr. Wynder's paper in the Journal of the American Medical Association on smoking and lung cancer and subsequent papers by Levin et al. (1950) and Doll and Hill (1950) had dramatically changed the landscape. The paper by Wynder and Graham (1950) on smoking and lung cancer had become the basis for the rapidly growing case control studies in chronic disease epidemiology, especially cancer epidemiology. Smoking was now accepted as the primary cause of lung cancer and rates of cigarette smoking among my colleagues and faculty had dropped dramatically within a few years. I first got to know Dr. Wynder during the 1960s, when I studied the relationship of cigarette smoking to sudden cardiac death. His work in identifying the specific chemicals in cigarette smoke and how that might be related to various diseases was of critical importance in trying to understand the relationship between cigarette smoking and cardiovascular disease (CVD), especially sudden death. It is hard to believe now but in the 1960s, 70–80% of all of the sudden cardiac deaths in men were occurring among cigarette smokers. There is little question that the substantial decrease in cigarette smoking contributed greatly to the subsequent decline in first event sudden cardiac deaths out of the hospital, especially in young and middle-aged men.
⁎ Fax: +1 412 383 1956. E-mail address: [email protected]. 0091-7435/$ - see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.ypmed.2006.08.003
Dr. Wynder was a very unique investigator. First, he had developed one of the few and perhaps first centers with a primary emphasis on preventive medicine. The American Health Foundation and the Mahoney Institute for Health Maintenance in New York City were clearly unique facilities. Second, he had an unusual commitment to the combining and understanding of biology and pathophysiology of risk factors and disease as the basis for preventive action. It was his understanding of chronic disease pathophysiology, epidemiology, and public health that made him so unique. For example, the major criticism of the smoking and disease relationship was the lack of the identification of specific chemicals in tobacco smoke that caused disease. Many investigators, in some of our most outstanding institutions, argued that it was the psychology or the selection for cigarette smoking that was associated with the disease rather than smoking being in the causal pathway. Dr. Wynder's work at the American Health Foundation was critical in identifying specific chemical components in tobacco smoke that contributed to disease. Dr. Wynder and the American Health Foundation played, I think, the key role in developing the linkages between epidemiology and the study of carcinogenesis which is continuing to evolve to the present day. Tobacco smoking, he showed, was not just the inhalation of hot air. Perhaps some of his sharpest critics were exhaling a lot of hot air. Dr. Wynder played a major role in efforts to link environmental tobacco smoke to illness among non-smokers. His group evaluated the differences between side-stream and mainstream tobacco smoke and technology to measure exposure of non-cigarette smokers to the effects of cigarette smokers, such as the measure of cotinine—a nicotine byproduct in urine. His emphasis on environmental tobacco smoke was an important stimulus for our study of “passive smoking” and CHD in the Multiple Risk Factor Intervention Trial (MRFIT) participants. It was not easy to change Dr. Wynder's opinion. Powerful lobbying groups continued to raise serious doubts about the adverse effects of tobacco smoking and especially second-hand or
L.H. Kuller / Preventive Medicine 43 (2006) 236–237
environmental tobacco smoke. Some of the major tobacco companies continued their efforts over these years to convince the public and especially the politicians in Washington that cigarette smoking was not a hazard. Many of us trained in academic medicine and public health had little stomach to battle the powerful tobacco lobby. Not Dr. Wynder. We were amazed to see how he was able to marshal powerful voices that, to this day, have contributed to the continued efforts to eliminate tobacco smoking. Students in public health are now trained in community organization, participatory research, and the need to increase social capital for public health. I strongly suggest that they carefully review the accomplishments of Dr. Wynder and especially the efforts of the American Health Foundation as a nidus for preventive medicine in the United States. His ability to raise social capital for public health and preventive medicine and the American Health Foundation was legion. Participatory research and programs were relatively simple. Dr. Wynder led the charge, got everybody in sight to participate, and those who didn't better get out of his way. In the early 1980s, I served on the Board of Scientific Counselors of the National Cancer Institute (NCI) Division of Cancer Prevention and Control under the able leadership of Dr. Peter Greenwald and Dr. Joe Cullen. Peter had selected a group of primarily cardiovascular epidemiologists and preventive medicine specialists for the board in order to strengthen the prevention agenda. Dr. Wynder's efforts with the board were a major component of the efforts to enhance preventive medicine research at the NCI. Dr. Wynder had a very strong interest in the interrelationship of diet to cancer. I think he felt very strongly that dietary factors and cigarette smoking were the primary determinants of cancer and that much cancer in the country could be reduced or eliminated by aggressive approaches to reducing cigarette smoking and changing the American diet. He was interested both in the addition of various nutrients, such as vitamins and minerals, and in a low fat diet, increased fiber, and fruits and vegetables. Dr. Wynder proposed in the 1980s that a secondary prevention trial to reduce recurrent breast cancer among treated breast cancer was an important issue. He persevered with his efforts to get a diet-breast cancer trial under way for many years, lobbying our committee, NCI Directors, and Congress. His efforts were ultimately successful, and the trial was finally begun (Chlebowski et al., 1993). The Women's Intervention Nutrition Study (WINS) began and finally in 2005–2006 the initial preliminary positive results have been reported at the American Society of Clinical Oncology by Chlebowski, Blackburn, Elashoff, et al. Dr. Wynder's concern about the importance of nutrition resulted not only in his commitment to do good prevention programs and clinical trials but also to develop a nutrition laboratory science program at the American Health Foundation, an important model for good epidemiology–nutrition research. Dr. Wynder “convinced” me to join the Editorial Board of Preventive Medicine. He had established the journal to enhance research and prevention in practice and theory of preventive medicine. During its early years, it was the official Journal of
237
the American Society of Preventive Oncology. Being a member of the Editorial Board was a unique experience. Dr. Wynder had us meet in the offices of the American Health Foundation in the Ford Foundation Building in New York City overlooking the East River. Epidemiologists are used to working in limited space and facilities. The magnificent offices of the American Health Foundation dedicated to preventive research and community prevention programs was an eye-opening experience. Dr. Wynder had raised the esteem of preventive medicine to new heights, not only by being in the upper floor of the building, but also by making people appreciate that preventive medicine was important. The board would meet for several hours. Dr. Wynder would come in, tell us what to do, and convince us of the importance of the journal, the need to educate both the medical and the lay communities about the importance of preventive medicine. He would tell us how great a job we were doing but that we needed to do better. We should make the journal more effective and use the journal to stimulate preventive medicine practice. He would then take us on a tour of the facilities, make certain to introduce us to the new and promising cadre of investigators who were always doing things that would revolutionize preventive medicine and enhance public health. You left the Ford Foundation Building and the American Health Foundation having received a very heavy dose of enthusiasm for preventive medicine from Dr. Wynder. Hopefully the therapy could last you for 6 months to a year, until the next meeting where he, again, would revive your spirits, convince you that preventive medicine was really important and that you were a member of his flock on your way to raise the banner of preventive medicine and conquer diseases. Dr. Wynder could make anyone a believer in preventive medicine. He combined an uncanny commitment to preventive medicine with brilliance in epidemiology and understanding of the mechanisms and pathophysiology of disease in order to improve health. Most of all, perhaps he was unique in our field by actually succeeding in obtaining “social capital” and recognition for preventive research. Dr. Ernst Wynder was a very strong advocate for preventive medicine. He successfully combined basic mechanistic laboratory and epidemiology approaches to the study of the etiology and prevention of chronic diseases. Perhaps more than anyone else, he was able to attract financial and political support for preventive medicine. References Chlebowski, R.T., Blackburn, G.L., Buzzard, I.M., et al., 1993. Adherence to a dietary fat intake reduction program in postmenopausal women receiving therapy for early breast cancer. The Women's Intervention Nutrition Study. J. Clin. Oncol. 11, 2072–2080. Doll, R., Hill, A.B., 1950. Smoking and carcinoma of the lung: preliminary report. Br. Med. J. 2, 739–748. Levin, M.L., Goldstein, H., Gerhardt, P.R., 1950. Cancer and tobacco smoking: a preliminary report. JAMA 143, 336–338. Wynder, E.L., Graham, E.A., 1950. Tobacco smoking as a possible etiologic factor in bronchiogenic carcinoma. A study of six hundred and eighty-four proved cases. JAMA 143, 329–336.