Book Review

The Power of Clan: The Influence of Human Relationships on Heart Disease

N Engl J Med 1993; 329:669August 26, 1993

Article

The Power of Clan: The Influence of Human Relationships on Heart Disease
By Stewart Wolf and John G. Bruhn. 171 pp., illustrated. New Brunswick, N.J., Transaction, 1993. $29.95. ISBN: 1-56000-043-0

The title of this book is misleading, for there is little in it on the subject of clans. Its subtitle, “The Influence of Human Relationships on Heart Disease,” is more informative, since the subject is the authors' study of heart disease and human relationships in the town of Roseto, Pennsylvania. The enchanting story of Roseto, which the authors have described before, is retold and updated in the current book. Dr. Wolf became interested in the small town of Roseto in the eastern part of Pennsylvania in 1962, when Dr. Benjamin Falcone, a practitioner there, told him that he had rarely seen any patient with myocardial infarction under the age of 50. This statement occasioned the speculation that the explanation might lie in the social and ethnic characteristics of the town's inhabitants, who, it was said, hewed to their ancestral ways to a greater degree than their relatives in neighboring towns.

In a 1964 study Stout and colleagues reported that there were fewer deaths from myocardial infarction in Roseto than in neighboring towns, even though there was no difference in the rate of death from all other cardiovascular causes (Journal of the American Medical Association 1964;188:845-849). They also noted that the “most striking feature” of Rosetans was their enjoyment of life and that they were mutually trusting and supportive, but that it remained to be determined whether “their sensible way of life contributes to their good health.” The article received a good deal of publicity. It also received its share of criticism focusing on such issues as case finding, population size, confounding factors, and other epidemiologic issues.

In subsequent studies Wolf and Bruhn were persuaded that the Rosetans' behavioral characteristics were responsible for their lower rate of death due to myocardial infarction. Some years later, in their first book, they reported a “gradual abandonment of the old ways in Roseto and the impending decay of the Old World culture” that “accompanied increased education and growing affluence” and prophesied an increase in myocardial infarctions as a consequence (The Roseto Story: An Anatomy of Health. Norman, Okla.: University of Oklahoma Press, 1979). In the present book this finding is reported, and both the initial lower mortality and the subsequent increase are presented as the consequences of major social changes.

Readers of the Journal will be familiar with the striking and well-documented decrease in total deaths due to cardiovascular disease among all ages and ethnic groups and both sexes in the United States and other countries since the early 1960s, to which the finding of increasing rates in Roseto is a remarkable exception. Moreover, the explanation that the increase in myocardial infarction is related to increased affluence and higher education and a shift to white-collar occupations is difficult to reconcile with many studies that show that it is precisely these characteristics that are associated with decreased mortality from cardiovascular disease.

The present book can be recommended to those interested in the Roseto story and its implications, because of the additional surveys that extend the length of follow-up and examine the prevalence of cardiovascular disease in several communities. The additional sociological observations that underscore the recent changes continue the part-survey, part-anecdote methods of previous work. It is curious that the issue of clans and their effects on heart disease that is the basis for the book's title receives scant attention except for a note that “weak evidence of clustering among the Roseto families” was found.

The reader will have to judge whether the authors' case is well made in the Roseto study, but it is undeniable that Wolf and Bruhn were among the first to popularize the idea that social factors are related to death from heart disease. Subsequently, several studies have shown that social support is associated with decreased mortality from coronary disease both in general communities and in cohorts of subjects after myocardial infarction. The mechanism by which this association operates, however, remains unknown.

William Ruberman, M.D.
New York University Medical Center, New York, NY 10016