«In an earlier study, covering a seven-year period from 1955 through 1961, a remarkably low incidence of death due to myocardial infarction was ...»
ROSETO REVISITED: FURTHER DATA ON THE INCIDENCE
OF MYOCARDIAL, INFARCTION IN ROSETO AND
NEIGHBORING PENNSYLVANIA COMMUNITIES
By STEWART WOLF. M.D. AND (by intvitation), KAY LINDA GRACE M.D.,
JOHN BRUHN, PH.D., CLARKE STOUT, M.D.
In an earlier study, covering a seven-year period from 1955 through 1961, a remarkably low incidence of death due to myocardial infarction was discovered in an all-Italian community, Roseto, in eastern Pennsyl- vania.1 In fact, coronary deaths in Roseto numbered fewer than half of those in the surrounding towns, Nazareth, Bangor, Stroudsburg and East Stroudsburg, where death rates approximated the national figures for myocardial infarction. The remarkably low death rate from myocardial infarction in the Italian community was most striking among the younger men, there having been, over the seven-year period of study, no coronary deaths below age 47. The validity of the interpretation of the findings was challenged2' 3 and defended.4 The original studies of Roseto and surrounding communities were sub- sequently supplemented by a thorough examination and testing of the populations.5 History, physical examination and EKG failed to reveal stigmata of ischemic heart disease among Rosetans under age 55, while such evidence was common among the other populations, including the relatives of Rosetans who lived elsewhere in eastern Pennsylvania, New Jersey or New York. Moreover, several deaths from myocardial infarction below age 45 were documented among those Italians who were born in Roseto but lived most of their lives in other communities. Fat intake, obesity, cigarette smoking and serum cholesterol concentration did not differ significantly among the towns studied. It was concluded, therefore, that the relatively low incidence of death from myocardial infarction in Roseto could not be explained by dietary, ethnic or genetic factors.
The distinct feature of Roseto was its remarkably closely knit social pattern. Unlike inhabitants of most American towns, Rosetans were found to be cohesive and mutually supportive, with strong family and commu- nity ties.6 The men in Roseto appeared to be the unchallenged heads of their households. The elderly were revered and, unlike most oldsters in University of Texas Medical Branch From the Marine Biomedical Institute, The at Galveston, Galveston, Texas.
MYOCARDIAL INFARCTIONAmerica, thev retained their influence on family affairs. Problems were customarily solved in family conclaves where each person took responsi- bility and often made some sacrifice. Less intimate, but nevertheless very close, were ties to neighbors and others in the community. There was great civic pride. Roseto held an enviable record of always "going over the top" in community drives and in providing prompt financial assistance to flood-torn or other disaster areas around the world, especially in Italy.
The overall atmosphere of the townl was one of mutual support and understanding, and unfailing sustenance in time of trouble.
CHANGING PHILOSOPHY AMONG THE YOUNGIn the initial examinations of Rosetans, carried out in 1962 and 1963, the younger Italian men whose grandfathers or great-grandfathers had immigrated to Roseto gave evidence of only a halfhearted commitment to the prevailing old world philosophy of family and community solidarity.
They had been spared the experience of their relatives a generation older who had had to bear social discrimination at the hands of their AngloSaxon neighbors. Discrimination against Italians was no longer practiced.
In fact, by now, Rosetans had achieved a degree of economic success that made them an object of admiration and even envy in the eyes of their neighbors. In the course of our sociologic interviews, most men under 35 years of age expressed conventional American attitudes and betrayed little interest in the old world values and standards. In 1965, a more thorough sociological survey was conducted by Dr. John Bruhn in which 86% of the adult inhabitants were interviewed in their homes.7 It was not surprising that by this time substantial changes in the prevailing mores of Roseto were occurring. In view of these social changes we predicted that the relative immunity from early death from myocardial infarction would soon be lost. A subsequent intensive follow-up study of eighteen family units, made in 1972, confirmed the accelerating pace of acculturation and elicited sharply contrasting responses from representatives of three generations to social change in the community.8 The formerly tight cohesive social structure was noticeably looser. Several young men had married non-Italians. The attendance at the men's clubs had fallen off, and Rosetans were beginning to join country clubs. Local church attendance had declined, too, and Rosetans were beginning to attend churches in other communities.
The present study of mortality statistics from 1962 through 1970 was undertaken to strengthen the initial findings and to test the current trend by adding nine years to the original mortality data from two of the communities, Roseto and Bangor, and four years to the data on predominantly German Nazareth. The people of Bangor, originally of English and WOLF ET AL.
102 Welsh descent, are now mixed with those of German, Italian and other ethnic backgrounds. Roseto's population is still 95 per cent Italian. Most inhabitants are descendants of families who immigrated in 1882 from Roseto, Valfortore, Italy.
METHODS Like those from the earlier published study,' the data were gathered initially from death certificates.* All cardiac and cardiopulmonary diagnoses were screened as well as other sudden deaths, whether they occurred near home or away from home. The information was then supplemented by a review of hospital records with particular attention to EKG tracing, histories and autopsy findings. The autopsy data were of little value because of the small number of autopsies. When possible, further supplementation was achieved by tracing the patients' records to the offices of their physicians. For the period 1966 through 1970, mortality data were gathered for Roseto and Bangor only. A local Italian plhysician, who was well acquainted with the inhabitants of both communities, supplied detailed clinical information on each death as it occurred in hiis own patients as well as in patients of other neighborhood physicians. In addition he supplied a description of the social and familial circumstances prior to and at the time of each death. Other local physicians also supplied supplementary information.
In order to avoid, if possible, overlooking any "coronary" death, records rep)orting all cardiac conditions, including rheuinatic and congenital heart disease, chronic obstructive pulmonary disease, hypertensive heart disease and others, were given careful study. All cardiac deaths were theni divided into three major categories: 1) death from myocardial infarction, proven anatomically, established clinically or presumed on the basis of previous history and circumstances of death; 2) deaths from arteriosclerotic heart disease without evidence of myocardial infarction; 3) deaths from hypertensive heart disease, congenital and rheumatic heart disease, and instances in which the evidence favored emphysema or pneumonia rather than any form of heart disease.
RESULTS Table I indicates the percentage of population at risk in eaclh age group and compares the rate of myocardial infarction in the initial survey withi that of the current survey of the three Pennsylvania communities for 1955 through 1961 and 1962 through 1965, and for 1966 through 1970 for * Obtained with the kind assistance of Mr. William R. Dixon, Director, Division of
25 Baingor and Roseto only. Table II illustrates the distributions of other cardiac deatlhs.
For the years 1955 through 1961, the death rate from myocardial infarction in Roseto among men under age 65 was a small fraction of that in the other two communities. In the 1962 through 1965 survey the Roseto rate had apparently risen to about 20% of that in the other two communities, with no deaths in Roseto below age 55, whereas in Bangor and Nazareth coronary deaths in the fourth and fifth decades were recorded.
By 1970 the death rate from myocardial infarction had clearly risen, the rate for Rosetan males under age 65 having reached nearly %rds that of neighboring Bangor. Although the age distribution of the population at risk hacd niot chlanged significantly, both males and females in Roseto were (lying at miore than twice the rate recorded in the original seven year stutly sample covering 1955 tlhrough 1961. Because the numbers are small, statistical significance cannot be attached to the apparent increasing 104 WOLF ET AL.
1955-1961 1962-1965 1966-1970 (1958) (1963.5) (1968)
death rate from myocardial infarction in Roseto. The differences between Roseto and the other two neighboring communities, however, are highly significant. Comparing coronary deaths below age 65 over the entire sixteen year period in Roseto and Bangor yields a highly significant p 0.001.
Although insufficient time has passed for any firm inference regarding the apparently rising death rate from myocardial infarction in Roseto, it is tempting to speculate that it may reflect the changing social philosophy and practices. During the first six months of 1971, while the 1970 survey was being made, two men in the age group 35 to 44 died of well-documented myocardial infarction. They were the first deaths in Roseto in that age group in the more than sixteen years of study. Detailed data were gathered on both men. One had been a subject in the medical survey on two occasions, 1962 and 1965. Both of the young men had deviated widely from the cultural norm of Roseto, and both had been excluded to a considerable extent from the mainstream of community life.
Subject A was born in Roseto, the oldest of four children, three brothers and one sister. In addition, there were three half-brothers and five half-sisters from his mother's previous marriage. His father, a carpenter, had immigrated from Italy and died at age 72 of aplastic anemia. His mother, who had diabetes and hypertension, died at 64 of myocardial infarction.
Mr. A graduated from high school, worked as a carpenter, and at 25 he married a German girl 20 years old, also a high school graduate. He was Roman Catholic, and she converted to Catholicism. He described himself as a tense, nervous person who found it difficult to relax because "I feel I need to get things done and can't waste time."
Two years after the marriage Mr. A started his own construction business in a town about 20 miles away. He worked overtime and smoked three packages of 105
MYOCARDIAL INFARCTIONcigarettes a day for 20 years. Neither he nor his wife were members of social and civic organizations in Roseto. He had no close friends in Roseto. The marriage yielded four children. His wife resented the amount of time his work kept him from home. Her interest was in family life. His was in making money. His mother died when he was 28, "the most unhappy time in my life. I tried to lose myself in work."
He said he had thought about moving away from Roseto "to get closer to my business."
At age 29, Mr. A was first hospitalized for chest pains wlhen the construction business failed. After bankruptcy he founded a new company. This time the business succeeded financially and Mr. A "lived like a king." He traveled to Puerto Rico, Las Vegas, gambled at the races and bought expensive cars. He spent about $1,000 weekly, gave wrist watches to the children of his relatives and responded generously to others who asked him for money or gifts without concern for repayment. He kept the problems of running the company to himself. His friend said "you would never dream he had pressure on him unless you knew him. He always had it tough, but managed to get out of it." He enjoyed risk-taking. Twro months prior to his fatal heart attack, during a trip to Puerto Rico, he lost $9,000 in one night gambling.
He was hospitalized in the intensive care unit for chest pains following his discovery that a bonding company had issued a fakle bond in connection with a large contract. Upon being told that his EKG was normal, lie signed himself out of the hospital against medical advice, and engaged in a poker game until the early hours of the morning. During the two weeks following his hospitalization, he made ten business trips to adjoining towns in addition to finally reconciling the bonding problem. The day of his death, he engaged in a fist fight with a drunk, was arrested and required to post $1,000 bail in cash. Later that day he attended the wake of a friend in a nearby city and, upon returning home, collapsed and died suddenly at age 39.
Subject B was born in Plhilipsburg, New Jersey, the eiglhth of ten children (six boys and four girls). Nine siblings are living. His father, a laborer born in Sicily, died at 49 of myocardial infarction. Dating from the death of her husband, his mother had paroxysmal auricular tachycardia, but lived until age 78.
Mr. B. graduated from higlh school but could not afford college. He married at age 24 to a Rosetan girl three years younger than he, and moved to Roseto. They had two children, one son and one dauglhter. He worked at the same job as a clerk typist for 22 years, typing 100 words per minute with t-wo to four fingers. He did his job well, but begrudged the fact that he did not have a college education. He got on very poorly with his wife, wlho kept him in debt by continually buying gifts for her relatives and expensive clothes for herself and their daughter. He tried to make up for the financial drain by working overtime.
He had a long history of financial and marital trouble. According to a brother, "His whole life was under stress. His wife would harp at him like an old shrew. If he would have had a happy home life he would have been happy living in Roseto."