The Seven Countries Study: Yugoslavia

Why Yugoslavia?

The questions that Keys and his colleagues addressed in Yugoslavia were based on preliminary evidence developed by Ratko Buzina and his local associates in the early 1950s. They had found remarkable differences in dietary fat intake and in serum cholesterol levels between the meridional region of Dalmatia and the eastern plains of Slavonia in Croatia. Another diet contrast tested in Yugoslavia was the effect of predominantly animal fats in the east versus vegetable fats in the west.

Ratko Buzina met Ancel Keys through Joseph Brozek, who was on Sabbatical in Zagreb from the University of Minnesota. Buzina later spent 1956 in the Laboratory of Physiological Hygiene, studying dietary fat effects on blood coagulation.

During that year, he and Keys laid plans for the survey in Croatia. Later, the formal proposal for the Croatian part of the Seven Countries Study was written by Keys and Buzina in one day, as they sat on a bench in a lovely Roman park in the springtime.

Pilot experience in Yugoslavia also had revealed that farmers and fishermen in Dalmatia and farmers in Slavonia responded to surveys in consistently high numbers. In fact, the eventual survey response rate in Dalmatia was 98 percent, and in Slavonia, 95 percent. Parallel clinical and dietary surveys were first carried out in those areas in September and October of 1958 by an international team.

Dalmatia, First Round, 1958

The following personal accounts are taken mainly from journals I kept during the critical starting period for the Seven Countries Study surveys in Yugoslavia in 1958.

September 23 : Arrival

I arrived today in Yugoslavia by train from Munich, declaring our survey medical equipment at the Austrian border where there was only a cursory customs inspection. Our international team has assembled rapidly in Zagreb. As we explore the city, it shows evidence of former Austro Hungarian elegance, but in Tito’s Yugoslavia of today, it is poor and somber; only an occasional automobile is seen in the streets. Zagreb maintains, nevertheless, two symphony orchestras, a lively Ritz Bar and Esplanade Hotel, and a brand-new, high-rise building in mid-town. All this is amidst a profound urban depression, seemingly both economic and spiritual.

On our first evening in Zagreb – a Saturday – Buzina took Austin Heady, of London, and me to the local press club. It was decorated in dull brown, with food to match. According to Buzina, the jukebox and TV have ruined the traditional ambiance of the club. As we left the building, we encountered dances in halls all along the main street – people milling about drunkenly, in an eerie atmosphere of sad abandon.

The men in Zagreb run the gamut of physical stereotypes, from swarthy, mustachioed Montenegrins to wiry Serbian peasants to stately Croatian aristocrats. The women are equally varied, and some are striking, despite their attempts at East-Bloc haute couture.

September 26

This morning, before leaving for Split and the Dalmatian coast, a small group from our team went for a stroll above town to the villa of the wartime governor, a Nazi sympathizer. The villa is now a handsome inn and restaurant with a view over the foggy valley and its autumnal woods, the city in the far distance.

Later, after a rickety train trip out to the coast at Split, we narrowly missed a ferry to our destination, Makarska, and so spent a sunny afternoon touring Diocletian’s Palace, the grounds of which embrace two thirds of the town. A hundred-year renovation plan for the palace is underway.

The ferry trip down the coast was delightful, but we were exhausted by the time we checked in at Hotel Jadran, our central headquarters in Dalmatia. All slept soundly in preparation for the first day and formal opening of the Seven Countries Study.

September 27

Makarska is a small port on the meridional edge of a severe plateau of gray, crystalline limestone abutting the Adriatic and extending deep into the interior of Bosnia-Herzegovina. The seaward slopes are terraced in vineyards and ancient oliviers. This morning, shepherds huddle in the dawn, housewives scurry toward the village pumps, and farmers move into the olive groves, all preoccupied with survival in a land where water and soil are scarce. In contrast to the rudeness of the land, the sea is calm and magnificent. Through a soft haze, the Adriatic archipelago is barely visible, mysterious, on the horizon.

Our first days in the Hotel Jadran are occupied with training and celebrations with colleagues, spouses and international ‘parachutists’ into this auspicious opening of the Seven Countries Study. Intensive planning meetings and discussions go on through the day, and in the evenings, long and formal dinners. Once these opening ceremonies are completed, we trust the dignitaries and hangers-on will depart, leaving the working survey team to its task.

September 28 : Survey Day 1

We all rose early this morning to say good-bye to Paul Dudley White. This popular and distinguished Boston cardiologist – physician to presidents – shows little evidence of aging, in gait or mentality. He is always charming, a bit garrulous, and perpetually curious.

His concepts about the prevention of heart attacks are as simple as they are powerful. For example: ‘A heart attack after age eighty is the work of God; before age eighty, a medical failure.’

In the first survey village, of Tucepi, just south of Makarska, there was a five-minute power failure today that required a call to the central power station which promised no further breaks (eventually proving a false promise). Our technicians are largely inexperienced, but they are industrious and eager to learn.

The clinicians, in contrast, are well trained, familiar with American nomenclature and literature, and make thorough examinations while remaining largely on schedule. The electrocardiographic room is the usual survey bottleneck, but today we were on track. Only two men were excluded from the exercise test, one due to emphysema and the other for hip disease.