The onset of the epidemic
This has been supplemented by a further Post describing in detail the onset of the epidemic, which occurred after about 1924. Much of the original work had been published in the British Medical Journal in 1963, by Dr Maurice Campbell, a highly respected and pioneer cardiologist in the UK. As with all epidemics, that of CHD had to become well-established before its presence could be recognised.
The peak of the epidemic
I also described the peak of the epidemic in about 1970. This was the time that I was heavily involved in emergency medicine, and experience of "heart attacks" was then so very different from what we see today. We would see people, mainly men, admitted via the emergency department (where I worked) every day, in whom the clinical features of severe myocardial infarction (MI, heart attack) were glaringly obvious. They had experienced severe crushing chest pain, and about had 50% died before they got to the hospital: sudden death was a major clinical presentation of CHD. Those who made it to the emergency department were usually very cold and clammy with low blood pressure – they were in cardiogenic shock with high risk of acute left ventricular failure and pulmonary oedema. Recorded hospital mortality was as high as 35%. Cardiac defibrillation had only just been introduced and coronary care units were only in a stage of development. The ECG was used in diagnosis and usually showed the appearance of Q waves, very rarely seen today, MI being a much milder condition than it was then. Cardiac enzyme testing was undertaken but it was not usually necessary for diagnostic purposes.
The decline of the epidemic
I have also described the unexpected decline of CHD deaths after about 1970. The decline was slightly earlier in the USA. The presence of an epidemic had been denied by most people, claiming that the data were unreliable and that the condition had always been present. Most of these people had probably never attempted to investigate the data and had never read the papers of Dr Maurice Campbell.
However the rapid decline of CHD deaths could not be denied: it occurred at a time of good quality data collection in many countries and standardised by the World Health Organisation (WHO). When it was realised that CHD deaths were in sharp decline, the great surprise was such that in the USA a Bethesda Conference was called by the National Institutes of Health (NIH) in 1978, the purpose being to explain this unexpected decline.
The result was the establishment of the MONICA project (Multinational MONItoring of trends and determinants in CArdiovascular disease). After 20 years it concluded that the decline of deaths was mainly the result of a decline of heart events rather than more effective treatment. No conclusion was reached concerning either the specific cause of the epidemic or its decline.
My Posts were concerned with the UK experience, which had been very obvious to me. I have been puzzled as to why so few people had recognised that there was a very serious epidemic of CHD deaths in the UK. I find the lack of curiosity very disappointing, especially a lack of curiosity that deaths from CHD had spontaneously gone into sharp decline.
But it was in reality much more than an epidemic. It was a pandemic, occurring in all continents simultaneously, and in effectively all nations in the temperate zones of the planet.
Dr William G Rothstein
The nature of the pandemic is now described in a new book entitled "The 20th Century Pandemic of Coronary Heart Disease". Its author is Dr William G Rothstein, Professor of Sociology Emeritus at the University of Maryland, Baltimore County.
The book is clear and concise, easy to read but of course the reading of data is slow but essential to full understanding.
The author explains the problems with classification during the onset of the pandemic. The terms used were "angina pectoris" in the years 1900 to 1930, and the new term "diseases of the coronary arteries" after 1930. The International Classification of Disease (ICD) was introduced in 1948, with later revisions, now revision 11. The new term "ischaemic heart disease" (IHD) ,which is the same as the now more commonly used "coronary heart disease" (CHD), was introduced in 1968.
Rothstein confirms that the emergence of the pandemic of CHD "did not receive the attention that it deserved". This is true as people did not appreciate that there was even a national epidemic.
I have stated previously that the rapid decline of the pandemic has been effectively denied by the medical profession, probably because a reason for it could not be envisaged. Rothstein's states: "The experts' fatalistic acceptance of of coronary heart disease as the result of lifestyles in modern societies produced amazement and confusion among them when coronary heart disease mortality rates began to decrease steadily and substantially in the 1970s and 1980s in the United States and other advanced countries."
I mentioned above that the surprise was such that the NIH Bethesda Conference was assembled in 1978. Rothstein draws attention to the comment from a participant in the conference: "The announcement for this reversal in the long-term trend [of CHD deaths] was received with great astonishment, both in the United States and other countries." This "astonishment" was kept very quiet in the UK, if not in other countries.
The epidemic in North America
The author has assembled data mainly from the USA. These have come from national and state statistics, but also from Life Insurance organisations, which in the early 20th century have been more concerned with accurate cause of death data than national and state registries.
A simplified presentation of these data are shown in Figures 4 and 5 below.
Rothstein describes the epidemic of CHD in the USA as having the same time characteristics in all states, but the highest death rates in the north-east states.
He describes the epidemic in Canada as having the same characteristics as in the USA.
The pandemic in other continents
He continues to identify that there was a true pandemic. The sudden appearance and decline of CHD deaths occurred in three continents continents simultaneously, North America, Europe, Australia and New Zealand.
He describes the pandemic in Western Europe, the UK having by far the best data collection. He identifies that mortality rates from CHD were highest in countries north of the 51st parallel (north of 51 degrees latitude), that is Ireland, UK, Belgium, Netherlands, Denmark, Norway, Sweden and Finland. They were lowest in the southerly European nations, Portugal, Spain, France, Switzerland and Italy. Importantly Rothstein notes that the data indicate that the peak and decline of the pandemic was simultaneous in all European countries, for all age-groups and for both men and women. Reliable data are not available for eastern European countries.
The book also describes the pandemic in Australia and New Zealand, with good quality data indicating a peak and decline of CHD death rates simultaneous with Europe and North America.
The pandemic appears not to have occurred in Central and South America. The exception is Argentina, which experienced the pandemic but in a milder form compared other continents. Central and much of South America are effectively tropical, such zones having not experienced the pandemic of CHD. Argentina is clearly in the southern hemisphere temperate zone.
Rothstein indicates that there appears to be a background form of CHD that was present before the pandemic, and is now appearing in the present post-pandemic era. The background CHD was and now is a disease of the elderly. The characteristic feature of the pandemic is that it caused the deaths of millions of people (mainly men) in middle age. It is this that is coming to an end.
The "non-causes" of the epidemic
The purpose of the book is to describe the pandemic, not to explain its cause. However Rothstein looks briefly at suggested causes of the pandemic of CHD and finds them all inadequate to explain it. He emphasises that the simultaneous rise and fall of the epidemic in all continents indicates a single and world-wide cause.
Diet - No dietary factor has been show consistently to be a a causative factor of CHD, and there was no significant change in the American diet between 1920 and 1950. Rothstein states that it is inconceivable that a single dietary factor could explain the rise and fall of the pandemic in all continents simultaneously. The appearance of "fast food" (which many consider to be bad for us) was in the 1970s, at the time of rapid decline of CHD death rates.
Cigarette smoking Although an accelerating factor of CHD, cigarette smoking cannot be regarded as the cause as toward the height of the epidemic, similar proportions of smoking and non-smoking proportions of the population died from CHD. Rothstein indicates that the rapid decline of the CHD pandemic occurred at a time when there was no reduction in lung cancer deaths, a reliable measure of cigarette smoking death.
In all nations experiencing the pandemic of CHD the incidence has been about three times higher in men than in women.
At the time of the decline of the CHD pandemic the prevalence of diabetes was unchanged. Diabetes could not have been a significant causative factor of the CHD pandemic.
The decline of the CHD pandemic has occurred at a time of concerns about the increasing prevalence of obesity.
Changes in lifestyle risk factors were not responsible for the emergence or decline of the CHD pandemic.
Statin drugs were introduced after the major part of the decline of the CHD epidemic and had no obvious impact.
In a previous book that identified the epidemic of CHD in the USA, Rothstein similarly eliminated a reduction of known risk factors as responsible for the epidemic and its rapid decline. In a review he was criticised "for not providing an alternative explanation". This is a false criticism. It was and still is not Rothstein's responsibility to identify the cause that has eluded all of medical science internationally. Just because he cannot identify an alternative explanation does not mean that one of eliminated "explanations" must be correct.
However it is probably true that once all known risk factors have been eliminated as the cause of the epidemic of CHD, people somehow seem to "switch off" and stop thinking, as though they do not want to know the truth.
And so it is in Rothstein's book The 20th Century Pandemic of Coronary Heart Disease. The identification of the cause is not offered. Rothstein's purpose is to identify what the vast majority of people (including medical professionals) are unaware of: that during the 20th century the world witnessed one of the most serious pandemics of all times.
Rothstein states that it is "....inconceivable that the many advanced countries on three continents that experienced the pandemic underwent identical changes in their diets and lifestyles at the same times before the emergence of the pandemic and identical reverse changes in their diets and lifestyles at the same times before the decline of the pandemic."
I have suggested in a previous Blog Post that the only plausible explanation of the pandemic of CHD death must be an environmental biological agent, in other words a micro-organism. Only this would affect all continents simultaneously, with a rapid appearance of the disease and then a rapid decline as inherited herd immunity developed. A specific organism has not yet been identified, but a search unlikely to have even started. It is always after the acceptance of an epidemic (or pandemic) being due to a micro-organism that this line of investigation occurs (for example, AIDS and HIV).
CHD in the 21st century
Rothstein indicates that in the 21st century, in the post-pandemic era, CHD became primarily a disease of the very old, as it had been a century earlier.
He suggests that the need for restraints in health care expenditure in many countries necessitate the re-evaluation of methods of prevention of the condition in healthy persons, including accepted risk factors.
He wonders if statin drugs currently used widely in healthy people are necessary in the post-pandemic era.
William Rothstein presented a great deal of supportive data in his book. His descriptive data from the USA was divided into the groups White Men, White Women, Non-white Men, Non-white Women.
During the CHD pandemic deaths rates were lower in women than in men. The development of the CHD pandemic was slightly later in non-whites compared to whites.
I would like to display some of Rothstein's data in a simplified graphical format, and in the interests of simplicity I will display only the data for white men in the USA, but for all men in the UK.
|Figure 1 All cause mortality in white men in the USA|
|Figure 2 Deaths from angina pectoris in white men in the USA|
|Figure 3 Deaths from disease of the coronary arteries in white men in the USA|
|Figure 4 Deaths from CHD in white men in the USA|
|Figure 5 Deaths from CHD in white men in the USA|
In Figure 6 we can see more recent data, again for simplicity just white men in the USA. Between 1970 and 2010 there was a reduction of all cause death rates in all age-groups, especially in those aged 65–74. It is this that has led to a great increase in the elderly and very elderly in the countries that experienced the pandemic of CHD.
|Figure 6 Death rates from all causes in white men in the USA|
|Figure 7 Deaths from CHD in white men in the USA|
We can see in Figure 7 that the reason for the reduction of all cause death rate was an even more dramatic reduction of deaths from CHD. This is the clear decline of the US epidemic. Please remember that statin drugs only came use in about 1990, and into widespread use after 2000. The decline of the pandemic was "spontaneous", meaning that it was not explained by a decline of known risk factors.
|Figure 8 All cause death rates in white men in the USA|
|Figure 9 CHD death rates in white men n the USA|
|Figure 10 CHD death rates in elderly white men in the USA|
|Figure 11 All cause death rate in men in the the UK|
|Figure 12 CHD deaths in men in the UK|
|Figure 13 CHD deaths in white men in the USA|
|Figure 14 CHD deaths in white women in the USA|
|Figure 15 CHD deaths in white men and women aged 65-74 in the USA|
I would like to thank Professor Rothstein for permission to present this review of his excellent and informative book, and also for his permission to present his data in a simplified graphical format.