THE LATE US SENATOR (D, KY) AND VICE PRESIDENT Alben Barkley enjoyed telling the story of his encounter with a disgruntled constituent. “ ‘I recalled how I had helped get an access road built to his farm, how I had visited him in a military hospital . . . , how I had assisted in securing him veteran benefits, . . . how I had got him a disaster loan. . . . Surely you remember all these things I have done for you?’ ‘Yeah,’ the fellow said, ‘I remember. But what have you done for me lately?’” In 1948, when Barkley was elected vice president (under President Harry S Truman), the National Heart Institute launched the Framingham Heart Study, an innovative and now internationally recognized population-based epidemiological project that brought together prominent scientists with members of the community of Framingham, Massachusetts. Thirteen years later, in 1961, the Framingham investigators introduced the term risk factor into the medical lexicon. They described the links between incident coronary heart disease and hypertension, hypercholesterolemia, and electrocardiographic left ventricular hypertrophy. Later reports described other risk factors, including smoking and diabetes. These early discoveries led to further research in risk factor elucidation and management, management that has contributed to the remarkable 50-year decline in cardiovascular mortality in the United States. Yet today, despite these extraordinary contributions, the value of epidemiology is questioned. Critics cite excess expense, repudiated findings, studies that offer small incremental knowledge, inability to innovate at reasonable cost, and failure to identify research questions with the greatest merit. At a time of unprecedented budgetary constraints, these critics wonder what epidemiology has done for medical science lately. A survey of the field suggests 2 answers: much and not enough. That epidemiology continues to provide important knowledge is evident in 2 reports published in this issue of JAMA. In one report, Safford and colleagues analyzed the course of more than 24 000 participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. Compared with white men and women, black men and women, who comprised more than 40% of the cohort, were more likely to smoke; be obese; and have diabetes, hypertension, and renal dysfunction. During 4 years of follow-up, black men and women had substantially higher rates of fatal coronary heart disease; in regression models, these higher rates were largely accounted for by the risk factors. The REGARDS findings are consistent with other reports of persistent health disparities and highlight the likely important role of risk factors, some of which are reversible, among some racial/ethnic groups. In another report in this issue of JAMA, Daviglus and colleagues describe the prevalence of cardiovascular risk factors in a large, diverse population-based cohort of US Hispanic and Latino individuals, including more than 15 000 participantsofCuban,Dominican,Mexican,PuertoRican,Central American, and South American origin. The burden of risk factors was high: 80% of men and 71% of women had at least 1 risk factor. Persons of Puerto Rican origin carried an especially high burden, with 25% having at least 3 risk factors. Risk factor burden was also associated with levels of education, immigration history, and preferred language. The reports by Safford et al and by Daviglus et al send a powerful and sobering message: despite 50 years of epidemiological knowledge and despite numerous therapeutic advances, risk factor burdens among minority populations are unacceptably high and consequential. Both reports offer, with appropriately cautious language, how their findings might translate into clinical and public health interventions that could reduce disparities. Still, critics of the US biomedical research enterprise suggest that not enough is being done. More specifically, they wonder why researchers are not working more closely with patients, clinicians, and policy makers to improve public health in a more direct way. Some authorities note that clinical and population research takes place within separate spheres from clinical care and public health and that long-standing US models for governing and executing epidemiological studies are being eclipsed by non-US studies that are much larger, yet considerably less expensive. How then can researchers more effectively work across the boundaries prescribed by traditional stakeholder roles— epidemiologists, clinicians, patients, policy makers, funders, regulators, foodanddrugmanufacturers,urbanplanners, and others—where suchboundariesmightbe impediments to scientificdiscoveriesandthe translationsandusesof suchdiscoveries that will best improve public health? Oneapproachtostrategicdecisionmaking, results-basedaccountability,offersatransformativeprincipleforworkingacross boundaries.First,definetheconditionsofwell-beingforwhich nosingle stakeholdercanbesolelyaccountableand thenwork
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Aug 2, 2013
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