Our Town: Tecumseh
Yes, said Jody Gray, an administrator in the Department of Epidemiology, she had the reprints. She hauled two old cardboard boxes out of storage, lugged them to a table in an empty conference room in SPH I, and flicked on the lights.
The boxes were stuffed with dusty three-ring binders, each plump with copies of scientific articles published 30 and 40 and 50 years ago, hundreds in all, from "An Epidemiological Study in a Total Community: The Tecumseh Project" in 1959 to "Marital Stress, Suppressed Anger and Blood Pressure" in 1986.
These articles are the fruits of a historic attempt to penetrate the unfolding mysteries of health and disease in a single, self-contained American place—the town of Tecumseh, Michigan, and the rural townships that bounded it. From its start in the late 1950s through the 1980s, it was one of the most important public health studies in the world.
Tecumseh yielded a treasure. In the 1950s, before the Tecumseh study, the major chronic diseases—heart disease, cancer, diabetes, arthritis, asthma, mental illness—were seen simply as the inevitable, unlucky burdens of life. By the time the study wound down more than a quarter-century later, it was generally understood that chronic diseases were associated with certain genetic and behavioral risk factors. They were not necessarily unavoidable. They could be minimized, even prevented. The Tecumseh study had much to do with that revolution in our understanding of disease and how to prevent it.
In the years just after World War I, Tommy Francis was a college boxer. Thirty years later, as Dr. Thomas Francis Jr., one of the great physician-scientists of his generation, he was well-liked for his sense of humor and his gift for friendship. But he retained an instinct for combat, a trait that melded with the social conscience he inherited from his father, a Welsh ministry candidate turned steelworker, and his mother, a Salvation Army nurse. Surveying the practice of medicine in 1950s America, Francis laced into his colleagues with the full force of his iconoclastic intellect and high idealism.
American doctors, he wrote, were practicing "preautopsy medicine"—that is, they spent most of their time treating patients who were too sick with chronic diseases to be helped. "Our so-called health statistics are commonly disease or death statistics," he wrote. "We . . . move blithely under the cover of a slogan, or in response to the call of the huckster, to realms of custodial care or administrative busyness with the end stages of disorder, while we withdraw from profitable investigation . . . in the areas of their causation and prevention . . .
"We have more effectively eliminated the buffalo [and] the whooping crane . . . than we have eliminated the causes of disease."
Few had done more to prevent disease than Francis. As director of the U.S. armed services' commission on influenza in World War II—this was early in his 28-year tenure as chair of epidemiology at the University of Michigan—he had been the key figure behind the first mass influenza vaccinations. Then, at the request of his protege, Jonas Salk, Francis had run the massive field trials for Salk's polio vaccine.
But long before the conquest of polio made Salk and Francis famous, a part of Francis's mind was shifting from infectious to chronic disease. If "every civilization makes its own diseases," as the medical historian Henry Sigerist wrote, then modern America, as Francis saw it, was cornering the market on afflictions associated with environmental toxins, improper diet, and inactivity.
To combat these ills, Francis believed, U.S. doctors must turn from "preautopsy medicine" to "preclinical medicine." That is, they should concentrate on identifying "the fundamental sources of health and disease," then promote the former to prevent the latter.
To this end, Francis embraced the idea of an in-depth study of a human population in its natural environment. Who would prove susceptible and who resistant to the major diseases? What factors in their lives—genetic, biological, social, economic, environmental—were responsible?
It would not be enough to take a mere snapshot in time. Instead, Francis imagined a kind of biomedical motion picture—a complex drama of health and disease unfolding in one place over many years, with threads of the story emerging and intertwining. "A new genre of medical ecologists, he argued, must "apply the fine sensitivity of the scientific artist and the broad perception of the community sculptor . . . to interpret the interplay of forces which result in disease."
This "total community approach—a "human population laboratory"—would be even more ambitious than the well-known study of residents of Framingham, Massachusetts, which dealt chiefly with cardiovascular health and only among adults. Single, point-in-time, cross-sectional studies were fine, Francis and his colleagues said, but they could miss key factors embedded in familial ties and the community's environment. The assembly of data from many such "total communities," they proposed, might one day make up "a comprehensive picture of the ecology of man."
This was heady, indeed, and at the funding agencies, there were skeptics. Chronic disease? That wasn't the proper target of epidemiology, they said; epidemiology was the study of infection and plague. But Francis's post-polio prestige was such that he soon won funding from the National Institutes of Health and the state of Michigan. This backing helped to seal the standing of Michigan's epidemiology program as "a truly great department," as the medical historian John R. Paul wrote, "a place where the whole philosophy of epidemiology was constantly explored."
But where should the study take place?
Francis sent a key colleague, Robert J.M. Horton, to scout for a town with a stable population close to Ann Arbor. They wanted an urban-rural mix and a variety of occupations. Several towns fit the criteria, but in Tecumseh—population 9,500, counting the farm townships—Horton sensed an intangible quality of public-spiritedness. Making the rounds of local leaders—the doctors at Herrick Hospital; the top dogs at the Chamber of Commerce; the ladies of the PTA and hospital auxiliary; bosses and workers at the big employer in town, Tecumseh Products; as well as the company's founding family, the Herricks—he found people eager to help. A few doctors worried the study might cut into their practices. But Horton reassured them. All UM wanted was data, he said, and all the data would be shared with the locals. So Tecumseh, 30 miles southwest of Ann Arbor, and the School of Public Health shook hands.
"It was a very nice small town," recalled Millicent Higgins, who was associated with the study for decades. "The people were, I would say, extremely cooperative and appreciative of this study."
Survey takers were recruited near Tecumseh—not from the town itself, since every resident participated in the study—then trained to administer questionnaires in person, house by house. Over 18 months in 1959 and 1960, they asked Tecumsehans about everything. If the town was the human universe in microcosm, wrote UM's Frederick H. Epstein, who would later direct the study, then that "universe has to be transected in manifold, frequently intuitive and uncharted ways; by social and geographical groupings; by living conditions such as overcrowding, access to good sanitation, exposure to such factors as climatic conditions, radiation, atmospheric pollution, industrial poisons; by consumption of different diets; by personal habits such as smoking, sleep, ways of relaxation; by psychological traits"—with all those factors to be weighed in the context of genetic makeup, constant "interaction with other living organisms," and the state of the subjects' health.
That first big census was taken from executives' stately Victorians to chilly houses where survey takers met with families around a single central stove. Everyone in town trooped to a basement clinic at Herrick Hospital for comprehensive physical exams given by UM physicians. A second full census was taken from 1962 to 1965—it took longer because there were more questions—a third, somewhat smaller one from 1967 to 1969, with many partial assessments in between and after. In the mid-1960s SPH epidemiologist Arnold Monto launched his own major studies of respiratory diseases.
Community participation rates topped 90 percent—an extraordinary level. In 1986 a Tecumsehan named Mark Hinkle, then 36, told a Detroit reporter the health study had simply been a part of everyday life as he grew up. "We went as a family," he said. "I did it because my mom and dad said, 'This is what we're going to do today.' . . . I can remember not wanting to give blood, and they explained we could help people everywhere and that we've got to do this."
Completed questionnaires went back to Ann Arbor, where clerks punched the data into computer cards. The sheer weight threatened to buckle the floor at the Victor Vaughan Building, so the study materials were trucked to a series of new addresses—North Main Street, Catherine Street, the Argus Building on the Old West Side. The staff used a computer so big that Nelson Meade, the administrator, had to have a crane lift it through an upper-story window.
As soon as the data became available, researchers in SPH, the Medical School, the Institute for Social Research, and other UM units began to analyze it. What role did dietary fat play in heart disease? Did high blood pressure and high cholesterol run in families? Exactly how much did physical activity vary by occupation? How accurately did mothers report their children's health? Why did early-onset heart disease run in families? How did the change of seasons affect the rate of acute infections? What were the socioeconomic determinants of obesity, and how was obesity related to cancer? How did genetics, diet, stress and personality differences affect blood pressure? Did gym classes really keep high school kids fit? How did drinking affect the risk of heart attack? How were infectious agents and chronic diseases related?
The value of studying the same people over many years became increasingly clear. In the mid-1980s, William J. Butler, an assistant professor of biostatistics, put it this way: "If we went into Detroit and identified people who developed cancer, could they tell us what they ate 15 years ago? . . . In Tecumseh, we go back to 1970 studies where we had questionnaires filled out on diet and we had their [frozen] serum. We could go back and see if Vitamin E was present in their serum. Very few populations in the United States would allow you to do that. It's just invaluable."
From such analyses those hundreds of articles emerged. Many, though far from all, dealt with cardiovascular health. The major findings added significantly to growing perceptions of health and disease that we now consider commonplace:
- Smoking, high blood pressure, a high-fat diet and sedentary lifestyle contribute to heart disease;
- High blood pressure early in life increases the risk of cardiovascular disease later;
- Early pregnancy means less risk of breast cancer; delayed pregnancy increases the risk;
- Hormone levels early in life predict relative risks of later osteoporosis;
- Strong friendships are associated with long lifespans.
In addition, Arnold Monto's work considerably extended our knowledge of common infectious diseases—including the common cold and influenza—and of the potential of antiviral agents. Quick teamwork in Tecumseh by Monto and Thomas Francis in the face of the 1968 "Hong Kong flu" epidemic not only fought the spread of the infection but did much to establish the important principle of "herd immunity."
Tommy Francis retired in 1969 and died only a few months later. Frederick Epstein took a position in Europe in the early 1970s. At roughly the same time, federal funding for health research began to shift from community studies to clinical trials of new drugs. Inevitably, the scope of the Tecumseh studies narrowed, and the clinical exams had to be dropped.
Yet UM's work in Tecumseh has continued. Under SPH epidemiologist MaryFran Sowers, a major study of the descendants of the original participants has identified the role of hormone levels in young-adult women in relation to the risks of arthritis and osteoporosis later in life. Important studies of hypertension conducted by Alan B. Weder, professor of internal medicine, are built on the historical Tecumseh data.
In the long run the Tecumseh study fell short of Tommy Francis's vision of a permanent "human population laboratory." Looking back recently, Millicent Higgins said, "I think it was a tremendous concept, a brilliant idea [that] was never realized fully." A study of Tecumseh's original scope was simply very difficult to maintain over the long haul.
Yet the rationale for Francis's vision still seems indisputable. As he wrote in the midst of the Cold War, "Freedom and democracy may seem like hollow triumphs if the hopes of life are submerged in a welter of disease. Security and longer life can be miserable acquisitions, if they mean only the continuation of unhealthy states. Preventive medicine can be our best demonstration to all the world of our belief in human life and happiness. Peace, health, and security are of the same fabric. We should weave more of it."
By James Tobin, an author and historian.
The Bentley Historical Library and the Tecumseh District Library assisted with images for this article.