A Change of Heart is a detailed account of the revolutionary Framingham Heart study — which, over the years, has provided conclusive evidence that cardiovascular disease is largely the result of measurable and modifiable risk factors. First begun in 1948, not long after Franklin Delano Roosevelt succumbed to a massive stroke, the study of over 5,000 citizens of Framingham, Massachusetts, changed the course of medical history. The lessons learned in Framingham allow each of us to control our risk of heart disease and stroke, two of the leading causes of death in the United States. Here is a clear-eyed and intriguing assessment of the achievements of this study and of its continuing importance to our health today.
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Daniel Levy, M.D., is the director of the Framingham Heart Study.
Susan Brink is a senior writers for U.S. News & World Report.
From the Hardcover edition.
A Killer of Paupers and Presidents
It was April 12, 1945, and the country was heartbroken. Franklin D. Roosevelt, the thirty-second president of the United States, died suddenly in what had come to be known as the Little White House, a cottage in the woods of Pine Mountain near Warm Springs, Georgia. The public was unprepared for his death, though for many months his doctors knew that he was gravely ill. In keeping with the culture of the times, his personal physicians hid the grim reality of the president’s failing health from the press, from the public, from his family—even from FDR himself. Casualty of an as yet unrecognized epidemic, the leader of the free world slipped away.
Roosevelt, his doctors, and the media had colluded to portray him as the picture of health. Long before he was elected president, in the summer of 1921 when he was thirty-nine years old, he fell victim to another epidemic. Polio rendered his legs nearly useless, his ability to walk nothing more than a simulation. He supported dead weight from the waist down with braces locked at the knee, and he would swing himself forward in a practiced rhythm between crutches. Throughout his life, the public saw him as strong, self-assured, and independent. No American was privy to the scene of Arthur Prettyman, FDR’s personal valet, strapping full-leg braces on the president as he lay supine in bed. The metal of each brace was painted black, and the president always wore black shoes and socks so as not to draw undue attention to the contraption. It was, like the title of Hugh Gregory Gallagher’s book, FDR’s Splendid Deception.1 His walk was seldom photographed, nor was the wheelchair on which he often depended. When a rare photographer violated the White House rule, Secret Service agents would seize the film and expose it. Only pictures of Roosevelt in a strong, erect stance or a comfortably seated position were permitted.
Rumors that Roosevelt was in poor health circulated during his first run for president and were blamed on the opposition’s attempt to derail his candidacy. The country was in the throes of the Great Depression. America was mired in despair, and Roosevelt needed to prove that he was strong and steady. To still the gossip, he released his medical records in 1931. His blood pressure was 140/100—the 140 systolic only marginally hypertensive, but the 100 diastolic a bad omen. Even the most brilliant medical minds of the time possessed neither the knowledge to recognize the gravity of his disease nor the tools to treat it. The numbers did not raise questions, but periodic reports continued to emerge that he was ill. So in 1932 he took out a life insurance policy for $50,000, reassuring his supporters by passing the medical examination at the age of fifty.Shortly after assuming the presidency in 1933, in what may have been a fateful decision, Roosevelt selected Admiral Ross McIntire as his personal physician. Dr. McIntire was an ear, nose, and throat specialist whose main concern would be the president’s numerous head colds and sinus problems.
Roosevelt took the helm of a nation at a time that would have taxed the hardiest of souls. America was then home to between 13 million and 15 million unemployed workers. A couple of million of them took to the road to find employment. They created a whole class of homeless migrants. They left behind dust-ravaged farms and boarded-up factories to wander the country in search of work. Hundreds of thousands of them lived at the edge of cities in tents and shantytowns, dubbed “Hoovervilles” in disparaging reference to the president they blamed for their lot. Panic about the economy had forced the closing of banks in thirty-eight states. The plight of a stricken populace surely took its toll on their leader during his first term. “I see millions whose daily lives in city and on farm continue under conditions labeled indecent by a so-called polite society half a century ago. . . . I see one-third of a nation ill-housed, ill-clad, ill-nourished,” he said in his second inaugural speech.6 And, in words that live in memory and history, he tried to reassure Americans at his first inaugural when he said, “The only thing we have to fear is fear itself.”
As the strain registered in medically measurable form, McIntire hardly made note of the rise in the president’s blood pressure. It was 169/98 in 1937 as Roosevelt began his second term. From then on, it would fluctuate, but remain abnormally high. His vital numbers rose to 188/105 in 1941, when the Japanese bombed Pearl Harbor. Still, as is typical, he had no outward symptoms of hypertension. Roosevelt launched a nationwide war effort, committing more than 16 million U.S. troops to the Allied cause in World War II. By the time American soldiers landed in Normandy in June 1944, his blood pressure was 226/118—a life-threatening level. The limited medical technology of the day, electrocardiograms and chest X-rays, showed a damaged, enlarged heart. Still, no one told FDR the bad news, nor did he ask.
Roosevelt was absent from the White House for nine weeks during the first five months of 1944.9 In those days, he would go to Warm Springs, an impoverished farm community eighty miles southwest of Atlanta, Georgia, for an “off the record” absence from duties, which amounted to much-needed bed rest. He had gained sustenance and rejuvenation from the town’s healing waters since 1924. These trips were about his only concession to poor health, and the reason behind them went unspoken. In an era when the media grant no mercy in exposing the secrets of public officials, it is difficult to fathom that back then journalists would comply with and help promote such a public deception. Dr. McIntire insisted that the president’s health was good, that Roosevelt’s blood pressure was normal for a man his age. In his treatment notes of April 1944, when the president’s blood pressure was 210/120, McIntire wrote, “A moderate degree of arteriosclerosis, although no more than normal for a man of his age.”
Everyone, it seems, was happy to go along with the opinion, particularly since at the time there was nothing to be done for escalating blood pressure. There is hardly an American today who doesn’t know enough to shudder at the president’s vital numbers. Meanwhile, McIntire remained concerned chiefly about FDR’s upper respiratory system. He dosed the president daily with nose drops and sinus sprays. Containing vasoconstrictors, the drugs did little to relieve his breathing symptoms, and probably further increased his critically high blood pressure.
If the public was fooled into believing it had a healthy leader, his family was becoming alarmed at his failing appearance. His daughter Anna, who lived in the White House in 1944, became conscious
of the darkening hollows under his eyes, the loss of color in his face, the soft cough that accompanied him day and night. To her observant eye, his strength seemed to be failing him; he was abnormally tired even in the morning hours; he complained of frequent headaches and had trouble sleeping at night. Sitting beside him in the movies, she noticed for the first time that his mouth hung open for long periods; joining him at his cocktail hour, she saw the convulsive shake of his hand as he tried to light his cigarette; once, as he was signing his name to a letter, he blanked out halfway through, leaving a long illegible scrawl.
Careful listeners to his radio fireside chats might have noticed, certainly by 1944, an audible short-windedness that probably reflected some degree of congestive heart failure. But Eleanor Roosevelt, who had little patience for the distraction of illness, attributed her husband’s malaise to overwork and stress. When doctors began to urge a reduction of meat in his diet, the First Lady had prime cuts of steak delivered to the White House because her husband loved them. By early 1944, however, she was ready to reject McIntire’s diagnosis and ask for a second opinion. It was Anna who, at last, pushed McIntire into sending the president to Bethesda Naval Hospital in March for a thorough examination.
There, a young cardiologist, Dr. Howard Bruenn, pronounced the president desperately ill. But McIntire carefully controlled the disclosure of all medical information, and believed Bruenn’s view of FDR’s health would disturb the president and his family. In fact, he balked at Bruenn’s recommended treatments, which included bed rest, a light diet, salt reduction, and a program of weight loss.McIntire watered down Bruenn’s suggestions until the “regimen amounted to no more than treating a cold.” He was even more upbeat with the public. At a press conference following Roosevelt’s medical exam he declared, “I can say to you that the checkup is satisfactory. When we got through, we decided that for a man of 62, we had very little to argue about, with the exception that we have to combat the influenza plus the respiratory complications that came along afterward.”
Historians speculate that as Roosevelt’s cardiac problems became more apparent, McIntire grew more determined to hide the reality that he had overlooked or concealed for so long. It was a reaction that “one can only assume was a protection of his turf and a desire to hide the fact that he had failed to diagnose heart problems earlier.”Years later, in a 1970 journal article called “Clinical Notes on the Illness and Death of President Franklin D. Roosevelt,” Bruenn wrote about the frustration of treating FDR. His account of the examinations and treatments of the president was the first medical data made available apart from McIntire’s memoirs. Bruenn’s account contrasted sharply with the self- serving recollections of McIntire, and Bruenn concluded by saying, “I have often wondered what turn the subsequent course of history might have taken if the modern methods for the control of hypertension had been available.” The president’s original medical chart vanished immediately after his death, and the most reliable record of his health during his presidency is the notes that Bruenn kept.
Bruenn persisted in speaking his mind, calling in other experts, and eventually he prevailed over McIntire. But even with focused concern, Bruenn was virtually powerless to control FDR’s severe hypertension. Roosevelt began taking digitalis, the only drug available for treatment of heart failure. At the very end of his life, he was prescribed phenobarbital, a sedative, which doctors at the time hoped would lower blood pressure. It proved ineffective. Lifestyle alterations for Roosevelt included a recommendation that he cut back on cigarettes from twenty a day to ten, but Bruenn was frustrated in his attempts to convince the president of the importance of it. Few doctors at the time considered tobacco a risk factor for cardiovascular disease, and Bruenn’s concern about FDR’s smoking was probably aimed at providing relief from a chronic cough and respiratory problems.
He also advised the president to limit alcohol intake to one and a half cocktails a day. This may have been prescient. Alcohol in high doses can cause blood pressure to accelerate, but Bruenn could not have known that then.
For the next few months, the president rallied publicly. With his country and millions of its troops depending on his strength of command, he felt he could not quit in the middle of war, and he decided to run once again for reelection. In the year before his death, Roosevelt’s blood pressure numbers through 1944, according to medical records, read like a recipe for disaster: March 27, 186/108; April 1, 200/108; November 18, 210/112; November 27, 260/150. And yet, during those months, he traveled to Hawaii to confer with top brass on military strategy in the war against Japan. He went to the Democratic National Convention in Chicago, but actually accepted the nomination for a fourth term in San Diego. He traveled to Alaska and to Washington State. He met with Winston Churchill in Canada.
Historians have shown that throughout this time he was quite ill. On one occasion, in the company of his son, James, he fell to the floor trembling with pain. Churchill even took the extreme measure of going to see Dr. McIntire because of his deep concern over Roosevelt’s health. McIntire continued to insist that the president was fine. Some members of the press actively promoted the deception that Roosevelt was in robust health. Henry R. Luce, editor of Life magazine, sorted through pictures of the president and said, “In half of them, he was a dead man. We decided to print the ones that were the least bad.” While giving a speech on a ship in Bremerton, Washington, Roosevelt sounded hesitant and uncertain as he gripped the sides of the lectern for support. Hugh Gallagher writes in FDR’s Splendid Deception, “The President’s balance was uncertain; the deck of the destroyer was not stable; he gripped the [lectern], his fingers clenched with fear and apprehension. As he spoke, he felt spasms of pain radiating from his heart. He burst into a sweat, and his delivery became confused and imprecise. That great, clear tenor voice became muffled. Afterward, his doctors found he had suffered an attack of angina—a severe pain caused by a restriction of the arteries bringing blood to the heart.”
It was the first of two suspected public attacks of angina. The second may have occurred as he delivered his final inaugural speech on Janu- ary 20, 1945. He stood to address the American people:
Mr. Chief Justice, Mr. Vice President, my friends, you will understand and, I believe, agree with my wish that the form of this inauguration be simple and its words brief. . . . In the days and years that are to come we shall work for a just and honorable peace, a durable peace, as today we work and fight for total victory in war. We can and we will achieve such a peace. . . . I remember that my old schoolmaster, Dr. Peabody, said, in days that seemed to us then to be secure and untroubled: “Things in life will not always run smoothly. Sometimes we will be rising toward the heights—then all will seem to reverse itself and start downward. The great fact to remember is that the trend of civilization itself is forever upward; that a line drawn through the middle of the peaks and the valleys of the centuries always has an upward trend.”
He delivered a message of hope, but the world was at the height of war, and the ceremony was solemn. The expense of a show of festivity would have been inappropriate, and the oath of office was taken quietly on the South Portico of the White House.
The impropriety of public celebration, ironically, served Roosevelt’s failing health. The address—fewer than five hundred words—was by far his shortest inaugural speech. It was to be the last time the public would see him standing. His secretary of labor, Frances Perkins, wrote later in The Roosevelt I Knew: “He looked like an invalid who has been allowed to see guests for the first time and the guests had stayed too long.”
As he departed for Yalta in early February to determine the destiny of Europe, Roosevelt looked gravely ill. In photographs, Winston Churchill and Joseph Stalin—who look hale and vigorous—appear to be hovering over the thin, drawn president. Roosevelt’s famous cape is askew, appearing more like an invalid’s blanket. Churchill’s doctor, Lord Moran, made these notations in his diary:
The president looked old and drawn; he had a cape or shawl over his shoulders and appeared shrunken. He sat looking straight ahead with his mouth open as if he were not taking things in. Everyone was shocked by his appearance. . . . To a doctor’s eye, the President appears a very sick man. He has all the symptoms of hardening of the arteries of the brain in an advanced stage, so that I give him only a few months to live. ...
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