Explaining the decline of coronary heart disease mortality in the United States in the 1960s: An historical analysis Open Access

Leighton, Leslie Steven (2015)

Permanent URL: https://etd.library.emory.edu/concern/etds/9z9030027?locale=en
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Abstract

Coronary heart disease (CHD) as a chronic disease came to attention in the United States and other countries in the early 20th century. Over the course of the 20th century its incidence rose to epidemic proportions and it became the leading cause of death in this country as well as most industrialized nations. Prevention and treatment of the disease evolved over the century and mortality plateaued in the U.S. in the 1960s and by all accounts began to decline by the end of the decade. The reason for the decline has been speculated and investigated since the 1970s, when it was first fully recognized, but has never been adequately explained. This dissertation takes a critical look at CHD and its evolution as a disease and major cause of death over the course of the twentieth century. More pointedly it attempts to explain the reason or reasons for the abrupt initial decline in its mortality which began in 1968 and has continued to date. As a result of archival research and oral histories, as well as statistical analysis, it is clear that there is no one single explanation for the initial decline in disease mortality. After 1974 it appears that both prevention and treatment played important roles in reducing the mortality of CHD but the initial decline in 1968 appears to have been the result of a number of factors, the least of which seems to be prevention. By the data amassed in this dissertation it is unlikely that mitigation of what are considered the major risk factors for CHD, including elevated serum cholesterol, hypertension and smoking, resulted in an initial reduction in mortality. Much more likely it was a number of incremental changes that occurred in the treatment of the disease, including the cardiac chair (an end to prolonged bed rest as treatment), the advent of the coronary care unit, the professionalization of the specialty of cardiology, Medicare and Medicaid that together led to a reduction in CHD mortality.

Table of Contents

Chapter 1: Introduction: The Evolution of an Epidemic 1

Chapter 2: The Decline 34

Chapter 3: Determinants of Health, Disease and Mortality 57

Chapter 4: The Role of Prevention: Myth of Hygieia 98

Chapter 5: The Role of Treatment: Myth of Asclepius 151

Chapter 6: Conclusion: What can and cannot be said 235

Appendix 1:

Figure 1: Per capita consumption of different forms of tobacco in the

United States, 1880-1995 263

Figure 2: Total and per capita cigarette consumption in the United States,

1900-1995 264

Figure 3: Decline in Deaths from Cardiovascular Disease in Relation

to Scientific Advances. 265

Appendix 2: Oral History Interviews: The Experts 266

References 277

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