September 9, 2000
Laura L. Scholes
It's a Tuesday morning in late June in downtown Bogalusa, and it's already hot--that white, hazy heat that settles down hard on Louisiana come summer. And on Bogalusa's main drag, the heat seems to be taking its toll. A woman stands fanning herself vigorously in front of Touch of Class Auto Detailing. Two kids out of school for the summer wander listlessly, kicking at the rocks and gum wrappers that have accumulated in the gutters.
Shirtless construction workers sweat as they throw sledgehammers into the side of the State Theater, finishing the work that neglect and time have begun. But inside 538 Columbia St., there is plenty of A/C and a flurry of activity. A distinct buzz is in the air because Dr. Berenson is coming in today. He's been on vacation for a couple of weeks and hasn't made his usual Tuesday visits to the main site of the Bogalusa Heart Study. The staff is itching to see him.
At 9:30, a slice of dusty, hot light breaks into the room and Gerald S. Berenson (B '43, M '45) enters--tall, imposing, with a shock of white hair. The buzz gets decidedly more animated when Berenson, handsome in his crisp blue and white seersucker suit, starts making the rounds to check in with everyone.
Rita Clayton, a retired RN, giggles and shakes her head of tight gray curls when he warns her to make sure she gets those blood sample labels on right, a task she could do with her eyes closed now after 28 years. And Donna Lee, the on-site director of the study who has also been here since day one, rolls her eyes when Berenson scolds her for coming in on her first day back after a sick leave.
All the people who work at the Bogalusa Heart Study home office on Columbia Street--Lee, Clayton, Acy Hartfield, Frankie McMillan, James Daniels, Doris Byrd, Elizabeth Thomas and Everett Watson--love Berenson, who founded the landmark study in his hometown back when his hair was still as black as fresh asphalt and his glasses weren't yet bifocaled. There are pictures of the old days stapled and tacked on the Heart Study's paneled walls.
There are pictures everywhere, in fact, that document three decades of community-based research, funded largely by the National Heart, Lung and Blood Institute, part of the National Institutes of Health. But back in 1972, when that first grant was awarded, no one could have predicted that there would end up being so much of a story to tell.
"We had no idea of the importance of the heart study when we started," says Berenson, who at 78 still exudes an energy that would wear out the average Gen-Xer. "We certainly didn't plan it that way. It took us three to five years to really begin to appreciate what we had started, and here we are close to 30 years later, still doing it."
Berenson adds that the story could not be told "without the unflagging efforts of many co-investigators and the wonderful team in Bogalusa. Our three community coordinators (Imogene Talley Barrisci, Betty Sul and Donna Lee) over the past 30 years were like angels."
The Bogalusa Heart Study is the only long-term community research project in the world with a biracial (African-American and Caucasian) population. In fact, much of the current thinking about what heart disease is and how we deal with it can be credited to Berenson's team and the research they've produced on the kids of this Louisiana town.
"There are no studies that are identical to it," says Berenson. "The other studies that have black/white populations do not have data from childhood; other studies that have children are all white, and the new Jackson Heart Study is all black adults. Very clearly, blacks have more high blood pressure, more kidney disease and more diabetes, and white men, particularly at a younger age, have more coronary heart disease. There is a tremendous power in looking at the biracial effect of heart disease. This has been a major strength of our study."
The Gaylord paper mill dominates the landscape of the "Magic City," looming large on the horizon no matter on what street corner or sidewalk of Bogalusa you're standing. The tall stacks discharge huge billows of gray smoke that blanket the town. That paper smoke is so much a part of the look and the smell of the sky that people wouldn't recognize their town without it. The 15,000 people who call this home are loyal to it, proud of the town's unusual beginnings as a private endeavor.
In 1906, the Goodyears of Buffalo, N.Y., were looking for a place to set up shop so they could dominate the timber industry. They found the perfect spot in the Pearl River basin across Lake Pontchartrain about 70 miles northeast of New Orleans.
Almost overnight they established the largest pine sawmill in the world--The Great Southern Lumber Company--and the town, Bogalusa, that surrounded it. In just a few months, the town's population was 8,000, almost all of whom worked for the mill, lived in houses built by the mill, went to schools started by the mill, stayed in shape at the architecturally grand YMCA (and YWCA) constructed by the mill and got medical treatment for free at a hospital founded by the mill (with doctors paid by the mill).
Today, Gaylord may not have quite the cultural influence over the town that Great Southern did, but it does provide the bulk of the economic base of Bogalusa. A smaller, though no less important, contributor to the culture of Bogalusa is Tulane's heart study. "If we went over to Wal-Mart, half of the people we'd see would have been through the heart study," says Acy Hartfield, retired principal of Terrace Elementary and now one of the study's most active and dependable staffers.
And it's not uncommon for study participants who have moved as far away as Seattle or Honolulu to make time to come through and be re-screened when they're visiting relatives in town. It's an almost unheard-of commitment. "I hope they feel like they're playing an important role, because they are," says Jeanette Gustat (PHTM '94, G '98), an epidemiologist with the heart study.
"A lot of them have a personal involvement with the study and they look forward to coming in, but I don't know if they realize how much they've contributed to the health of our nation. People on the other side of the world know, but the people here don't know how important the Bogalusa Heart Study is."
Originally, Berenson and his team went through the Bogalusa school system every three years or so and analyzed the students' blood for cholesterol, measured blood pressure, assessed height and weight, and conducted interviews about the children's and their parents' food choices and lifestyles. As the children grew up, study participants--many of whom have had between eight and 10 interviews by now--came to the Columbia Street offices for their exams.
These screenings allowed the heart study team to track the natural history of heart disease and nutrition status in this biracial community. The results are both striking and far-reaching: Berenson and his colleagues determined that you can see the risk factors for cardiovascular disease as young as age 2. "One of the things we could note even in childhood is that obesity was already present," says Berenson. "As the children matured, we began to see other risk factors increase."
For example, 20 percent of the African-Americans in the group are hypertensive, and 40 percent of white male participants have abnormal lipoproteins. Eighty percent of people in the study exceed the recommended daily fat intake and 60 percent exceed the cholesterol intake. Berenson found that nearly twice as many had high cholesterol and more than twice as many had abnormally high blood sugar, which is associated with diabetes. Some of the oldest members of the study already have contracted heart disease.
So what seems like common knowledge now--high blood pressure and high cholesterol are indicators of increased risk for heart problems; diet and lifestyle have an impact on heart disease--was pure speculation when the National Heart, Lung and Blood Institute gave Berenson the first grant in 1972 as one of 13 NIH-sponsored Specialized Centers of Research in atherosclerosis. These centers were established to investigate the major causes of cardiovascular disease: atherosclerosis, hypertension, pulmonary disease and thrombosis.
Berenson had been at Louisiana State University Medical Center 18 years when the study began, but for the last decade, Bogalusa has been the flagship study for the Tulane Center for Cardiovascular Health. From the beginning, Berenson questioned the concept that coronary artery disease and atherosclerosis were simply plumbing problems, a mechanical blockage of vessels, says Keith Ferdinand, a New Orleans cardiologist who worked with Berenson in the early 1980s as a cardiology fellow.
"The idea that cholesterol was related to coronary artery disease at all was considered theoretical at that time," he says. "If you saw a young person with a heart attack or atherosclerosis, it was considered an abnormality or due to genetics, but of absolutely no importance in terms of the burden of the disease on the population." Berenson didn't buy it.
"Dr. Berenson questioned the idea that hypertension was simply a disease of aging, and he thought that we, as adult cardiology fellows, should be more in tune with the concept that these were chronic illnesses that manifested themselves in childhood and adolescence," Ferdinand recalls. "This was a fairly revolutionary idea at the time, and something that the fellows weren't really sure was true."
To convince his young colleagues, Berenson would pile them into a van and drive them himself to Bogalusa to get them working hands-on, assisting the Bogalusa staff with the screenings--drawing blood, measuring height and weight, taking blood pressures. Not exactly the challenging stuff most post-MDs would be thrilled about.
"Most of the fellows were very reluctant to do it," recalls Ferdinand. "We wanted to be exploring the high-tech stuff, like the new electrocardiogram; we wanted to do coronary angiograms. But he wanted us to understand the importance of risk factors. And to him, it was just as important that we know how to do an appropriate history and physical exam and to understand the basic nature of the disease process."
Ferdinand says that--finally--medicine has caught up with Gerald Berenson. "While we have new forms of technology for the diagnosis of heart disease and failure always in development, I think it's now widely recognized that much of what we're dealing with in coronary artery disease has to do with prevention and that if we lower lipids and lower blood pressure and decrease obesity and educate patients, then that has more of an impact than doing a particular surgical procedure or coronary intervention in a particular patient. He was ahead of his time."
Folding chairs line the walls and fluorescent lights hum. Cereal, juice, raisins and Berenson's trademark graham crackers lie waiting on a table to break the study participants' 12-hour fast after they give a blood sample. On any given Tuesday, you'll find six or seven study participants hanging out here, sitting quietly with oddly forlorn pieces of colored yarn tied to their wrists, a practice left over from the days when screeners would see 50 children a day and workers needed a quick visual to match the child to his or her file.
In its heyday, there were 40 or so people working with the study to oversee operations and evaluate data. It was noisy then, filled with kids giddy over getting to cut class to get doted on by the Bogalusa workers and volunteers. "I was in the fifth grade when the heart study started, and my whole family's been through--my husband, my brothers, my sister, we're all in it," says Elizabeth Thomas, who as an LPN is now on the other side of the blood pressure cuff and has been working with the heart study for nine years.
"We knew it was research and our mama thought it was important for us to get the physical. But mainly we just enjoyed getting out of class." It's the physical exam aspect of the Bogalusa Heart Study that is perhaps its most unusual feature, and the one that tells the most about the study's commitment to the community.
"Dr. Berenson has taught me one very important thing, and that is that if you're going to do research, you must provide a service to the people who are giving you the research data. That is something I hadn't learned elsewhere," says Carsie Nyirenda (PHTM '97), an epidemiologist from Zambia who does data management and community outreach for the study.
"When the study was screening the children, he always insisted that they get a physical examination. Even now, people who come in get the full once-over--cholesterol, bloodwork, EKG, blood pressure. We identify people's problems; we tell people they have high blood pressure or diabetes, and Dr. Berenson makes a personal effort to get involved if there is a serious problem. And because we're in a small community, this kind of information spreads. They talk about it with their families and the people at their church. So, yes, we're doing scientific research--we've published over 700 papers and books--but we've also affected daily lives. That's what I think I'll remember when I look back at this experience years from now."
"We didn't have to give children a physical for the research, but Dr. Berenson wanted to do it for their benefit because some of them never got to see a doctor outside of the heart study," says Clayton as she's wrapping up another set of blood samples to be shipped to New Orleans for evaluation. "And over the years, they have found problems like high blood pressure--things that the person didn't know he or she had."
Acy Hartfield cuts in. "That's right. One thing about the heart study being in this community is that it has provided medical care to groups of people who normally wouldn't have had access," he says. "We have a Charity Hospital here, but you almost have to be dying to get in over there because of the wait. Dr. Berenson doesn't prescribe any treatment, but in cases where a red flag comes up, he will meet with the person and explain the problem and explain what they need to do or get them the help they need."
Hartfield should know--he was one of those people. When he was in the school system, he went through the screenings with his students and found out he had high blood pressure even though he had no symptoms. He's been on medication now for close to 20 years. But the hands-on nature of the research does not mean it is any less valid. "One lasting impact Dr. Berenson had on my career was his analytical honesty and integrity," says P. Michael McFadden (M '74), a cardiothoracic surgeon and surgical director of lung transplantation at Ochsner Medical Center who spent several summers in the lab with Berenson.
"He's not going to accept data that is not correct; it's going to have to be perfect before he reports it or exposes it. When I was working with him, if the data didn't indicate what he thought it should, then it was not to be fixed up and reported; it was discarded and the whole project had to start over again. That had a huge effect on my research career."
The 16,000 children who have produced the bulk of the data for the Bogalusa Heart Study are all grown up now (the eldest are in their mid-40s). And it's calmer on Tuesdays at the heart study office. No little girls gather to twitter about how squeamish the boys are about getting their blood taken. And adult study participants get to wash down their crackers with coffee instead of milk at breakfast if they want to.
At one point at the beginning of 1997, the study even lost its funding completely. They had to let staff go, and the town's support waned. But Berenson's team reworked the grant to give it a genetic focus and won back its NHLBI funding. The new grant of $4.5 million will support study activities until 2002 with a mission of examining the role of genetics versus environment in the development of heart disease.
Bogalusa researchers will look at diet, smoking, alcohol and education, and will look at genetics and racial contrasts related to heart disease.
"Getting this grant back was something we worked at very hard," says Berenson. "People at Tulane wanted us to retire, but I told them I don't know how to quit." Berenson's determination impressed some other heavy hitters: In May of this year, the study received a five-year, $3.74 million grant from the National Institute of Aging to continue screening the original participants to document the normal aging process in middle age.
"Cardiovascular disease is a main cause of disability and the leading cause of death among older Americans," says Andre J. Premen, director of the Cardiovascular Aging Program at the NIA. "With the continuation of this study, we will be able to look at how aging itself, beyond known cardiovascular risk factors, may affect cardiovascular health."
Laura L. Scholes is a free-lance writer based in Oxford, Miss. This is her first feature article for Tulanian. This article originally appeared in the Fall 2000 issue of Tulanian.
Tulane University, New Orleans, LA 70118 504-865-5000 firstname.lastname@example.org