community-wide rural cardiac health program

JAMA just had an article on a successful, long-term public health initiative for the prevention of cardiovascular disease in a rural low-income area in Maine (see cad risk prevention community prog JAMA 2015 in dropbox, or JAMA. 2015;313(2):147-155). this program involved a 40-year observational study in Franklin County, Maine, looked at the pre-intervention period of 1960-70, then the 40 year period thereafter in which sequential risk factor reduction programs were initiated, and compared this all to the statistics for the whole state.
background:
    --Franklin County is a rural, poor small county in northwestern Maine, with 22,444 residents in 1970 growing to 30,768 by 2010; predominantly white (99.9% In 1970 to 97.2% in 2010); increasing in elderly (those >65 yo, from 10.8% to 23.0%); decreasing younger population (those <18yo from 35.3% to 26.9%); increasing poverty (from 9.0% to 16.8%), though increasing % completing high school (57.2% to 87.9%). also more primary care physicians (ratio of population to PCP went from 1870 to 853)
    --programs (there was a long-standing partnership between medical providers/hospitals with community groups, including the the local University of Maine campus which developed a health education degree program and trained outreach workers. Programs supported by Federal grants). the initiatives included:
                ​--1974: hypertension program -- multidisciplinary approach with health coaches and nurses for education, screening and referral/followup, working in diverse settings: community, school, worksite and medical practices
                --1986: cholesterol program -- similar approach as with hypertension. used point-of-care lipid screening
                --1988: smoking cessation -- as above, but also developed in-class tobacco-related curriculum for students in K-12. also did community-based interventions (individual and group). tobacco sales "sting" operations by program staff, motivated students, with parental and law enforcement approval
                --1990: diet and physical activity interventions, including promoting heart-healthy menus in restaurants, schools and grocery stores; raised local funds to build a health and fitness center open to students and community residents.

results:
    -->150,000 documented individual community contacts with above programs over the 40 years
    --hypertension control increased from 18.3% to 43.0%
    ​--elevated cholesterol control increased from 0.4% to 28.9%
    --smoking quit rates improved from 48.5% to 69.5%
    -​-non-obstetric hospitalizations decreased by 17/1000 population
    ​--total mortality (adjusted for household income) had been higher in Franklin than in other Maine counties in the pre-intervention period of 1960-70, but after the interventions was substantially less than in other Maine areas. cardiovascular mortality also was significantly lower than in the rest of Maine (the figures in the article are pretty striking)

so, a really remarkable program, combining the components of sustained community empowerment and activism over 40 years, drawing on the skills of nonmedical and medical as well as nonprofessional and professional people, and with integration into a primary care medical system. some of the gains initially found tended to decrease over time, likely because of other communities in Maine emulating some of these programs (eg, many areas subsequently had dramatic decreases in smoking rates). 

the big lesson here is that this type of intervention can be a sustained one and lead to very impressive outcomes. is it generalizable? the short answer is: I think so. neighborhoods in urban cities often function as small communities (at least that is my experience both in Chicago and Boston). for example, the health center network in Boston (i believe the most extensive community-based system in the US) developed out of local initiatives within the different neighborhoods in Boston in the 1960's and 70's, to the point that they are very well-established community-oriented centers dealing with the array of medical and social issues in their communities.

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