Remembering Dr Marvin Moser

Dr Marvin Moser, one of the leading figures in the field of hypertension, and the first Editor‐in‐Chief of The Journal of Clinical Hypertension, died on November 13, 2014, at the age of 90.

Marvin Moser obtained his MD degree in 1947 from the Downstate Medical College of the State University of New York. He then did residencies in medicine at the Kings County Hospital in Brooklyn and the Montefiore Hospital in the Bronx before undertaking his fellowship in cardiology at the Mount Sinai Hospital in New York. After completing his formal training, Dr Moser served for 2 years as the Chief of Vascular Disease and Hypertension at the Walter Reed Army Medical Center in Washington, DC. For much of his career he was a Clinical Professor of Medicine at the Yale School of Medicine, a post he still held at the time of his death. And in a signal recognition of the outstanding career and public service of its alumnus, Downstate College of Medicine conferred on Dr Moser the honorary degree of Doctor of Science in June 2014.

It is remarkable that in the early 1950s, at a time when hypertension was not well understood and, for the most part, untreated by practicing clinicians, the young practitioner Marvin Moser was already identifying himself closely with this discipline. Those were days when most attention was focused on malignant hypertension that was imminently life‐threatening. With only a limited selection of antihypertensive drugs, consulting physicians were compelled to consider debilitating procedures such as surgical sympathectomy or strategies such as the temporarily effective but impractical “rice diet.”

But Marvin's natural curiosity and the influence of Dr William Dock, his professor and mentor at Downstate and Kings County Hospital, led him to a belief that hypertension might carry far greater prognostic implications than the immediate risk of major events, and he became one of the first investigators to explore new types of drug therapy for reducing blood pressure. In making his contributions, Marvin had to overcome the nihilistic attitudes of many of the influential experts at that time. Indeed, a common opinion advanced by leading cardiologists in the 1950s and even the early 1960s was that high blood pressure was a compensatory mechanism to overcome obstructive arterial disease and so ensure an adequate blood supply to the brain and other vital organs. Woe betide the clinician foolish enough to place patients at needless risk by reducing their blood pressures! Many years later, Marvin recalled those contentious days in his illuminating monograph: Misconceptions and Heroics––The Story of the Treatment of Hypertension from the 1930s.1

Those physicians who recognized that even moderately increased blood pressures were predictive of poor cardiovascular outcomes were hampered by the lack of effective and well‐tolerated drugs. In fact, it was only in the 1950s and the early 1960s when drugs such as thiazide diuretics and reserpine and other autonomic blocking agents became available that a rational basis for treating hypertension became possible. Even then, skepticism regarding the wisdom of treating hypertension remained. Indeed, this was only resolved when the landmark Veterans Administration studies conducted by Dr Edward Freis and colleagues in the 1960s established the clear cardiovascular and stroke benefits of treating hypertension. Aiding this recognition, of course, were epidemiologic data furnished by research such as the Framingham Study that emphasized the tight and continuous relationship between blood pressure and the risk of cardiovascular and stroke outcomes.

The National High Blood Pressure Education Program

Although Marvin Moser regarded himself as a traditional hands‐on physician, his greatest contribution to hypertension was to serve as its most effective public health advocate. The National High Blood Pressure Education Program (NHBPEP) was started under the auspices of the National Heart, Lung, and Blood Institute (NHLBI) in 1972, and throughout his career Marvin remained its principal champion. He held the title of Senior Medical Consultant to the NHBPEP from 1974 to 2005. Working with his good friend and colleague, Dr Edward J. Roccella, who served as coordinator of this program, Marvin Moser undertook the Herculean task of educating the American people––both health professionals as well as the lay public––about the critical importance of understanding, recognizing, and treating high blood pressure.

In 2012, in celebration of the 40th anniversary of the NHBPEP, Marvin Moser and Ed Roccella wrote an illuminating article titled, “The Treatment of Hypertension: A Remarkable Success Story,” which was published early in 2013 in The Journal of Clinical Hypertension.2 For any student of hypertension, this work provides a succinct but highly enlightening history of the field and represents an extraordinary example of how dedicated medical leaders can bring about dramatic changes in health care. Marvin's exceptional efforts certainly were recognized. In fact, a statement by the Centers for Disease Control and Prevention, published in 1999 and titled, “Ten Greatest Public Health Achievements––United States, 1900–1999,” listed the work of Marvin Moser and his colleagues at the NHBPEP as one of the 10 most important public health advances in medicine of the 20th century.3 A truly remarkable accolade!

One of the major methods employed by the Program was the use of public service announcements in the media as well as graphic posters and other sources of information designed to make the public better aware of the existence and dangers of high blood pressure. After 30 years of this work by Dr Moser and the NHBPEP, close to 90% of Americans knew of the importance of blood pressure. In their article detailing the history of the Program, Drs Moser and Roccella take justifiable pride in the ever improving control of hypertension in the United States and the fact that this accomplishment played a central role in the dramatic reductions in strokes, heart attacks, and premature cardiovascular deaths that were documented during this period.

A Connection to the World Hypertension League

One of the main achievements of the NHBPEP, in which Marvin took considerable satisfaction, was its focus on addressing health disparities among different communities. As it happened, this work was not only highly effective within the United States but became an important international success as well. Of note, these efforts played an important part in the establishment of the World Hypertension League (WHL), which used the Program's template to develop or contribute to the formation of hypertension societies in more than 150 countries. It is a notable and happy coincidence that 5 years after Dr Moser retired as its Editor‐in‐Chief, The Journal of Clinical Hypertension became the official journal of the WHL. All of us connected with this Journal have been delighted at the continuity of Marvin's early commitments with this important direction of the Journal.

The Joint National Committees

To practicing clinicians, perhaps the best‐known aspect of the NHBPEP's work was its sponsorship of the Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure (JNC). Marvin served as Chairman of the first JNC report published in 1977. This publication was a remarkable tour de force, because the Joint Committee actually represented more than 40 professional and related medical organizations across the United States. It speaks greatly to the efforts of Dr Moser and his colleagues to coordinate such a complex task and create a set of guidelines for hypertension management that represented the best scientific evidence and clinical experience available at the time. Subsequently, under the NHBPEP's sponsorship, there were new JNC reports every 4 or 5 years until the seventh report (JNC 7) in 2003. During this period, the JNC reports served as the authoritative guideline for the diagnosis and care of hypertension not only for the United States but throughout much of the world. The definitions of hypertension that these reports established, and the strategies for treating high blood pressure they recommended, became integral to clinical practice in hypertension throughout the world. To be sure, some of the recommendations were controversial, and not all recommendations were universally followed, but the JNC reports provided a strong basis for decision making in hypertension both in individual practices as well as at the public policy level. In the eyes of many of his colleagues, the creation of the JNC reports might be considered as Marvin Moser's single most visible contribution to the world of hypertension. It should be noted that in 2013 the NHLBI, which hitherto had been the formal sponsor of the JNC reports, decided that the development and publication of guidelines should henceforth become the responsibility of major professional societies rather than a government agency. But even as the development of guidelines now goes forward under a different banner, the legacy of Marvin Moser and his many colleagues will continue to have a strong impact.

Aside from his major responsibilities with the NHBPEP and the JNCs at the national level, Marvin Moser was highly engaged in his academic activities. He was a prolific researcher and writer. During his career he published more than 500 peer‐reviewed articles in the medical literature and a large number of chapters for medical texts. He was also responsible for five books focusing on hypertension and cardiology. But one of Marvin's most powerful contributions lay in reaching out to the general public. He was a co‐editor and contributor to the Yale University School of Medicine Heart Book, and beyond that he wrote several other highly readable publications designed to help patients and their families better understand hypertension and learn how adopting appropriate diets and lifestyle changes could enhance the treatment offered them by their doctors.

Surveying a Larger Picture

In late 2013, Marvin Moser contacted the current editors of The Journal of Clinical Hypertension and asked whether the Journal would be willing to publish a personal commentary, not on the subject of hypertension, but based on Marvin's view of the current state of medicine in general. The editors readily agreed with their old friend, and soon afterwards Marvin submitted a manuscript––in reality, an essay––in which he contrasted the world of medicine during his earlier career with what has evolved to the present day. This work carried the charming title of: Sixty Plus Years of Reflections on the Medical Profession By An “Old Timer.” 4 In his provocative discussion––in which he pulled no punches––Marvin pointed out how in many ways the practice of medicine has changed, often not for the better. His greatest concern was the “dehumanization” of medicine. He pointed out that younger practitioners now seem dependent on sophisticated and expensive testing and procedures rather than relying on their skills in history taking and physical examination. As further evidence of the growing separation between doctors and patients, he also pointed out the disturbing trend during patient visits for doctors to spend more time gazing at computer screens than looking at their own patients. Marvin expressed concern that doctors have lost much of their autonomy, and now are simply components of a large industry run predominantly for the profitability of large health care companies. It is very interesting that at that late stage of his career––more than 60 years after he graduated as a physician––Marvin still felt the need to publicly express his frustrations over these troubling changes in patient care.

Another of Dr Moser's concerns, which he also expressed verbally to his friends and colleagues, was that many contemporary physician leaders and their institutions had become unduly dependent on the pharmaceutical and device industries to support research and education. In this context, it should be remembered that Marvin felt his strongest affinity for the NHBPEP and so perhaps was somewhat mistrustful of industry, although he did recognize the major strides in medical progress created by relationships between physicians and industry. Indeed, this ambivalence helps illustrate a common paradox in academic medicine: After all, when Marvin Moser was actively involved in establishing The Journal of Clinical Hypertension he recognized that the success of the Journal, and the ability of its publisher to make it available to a large audience, would depend heavily on advertising and other support from industry. But, while acknowledging this need, as an editor Marvin was vigilant in preventing excessive control by industry over the writing and content of the articles that he accepted for publication.

This personal essay by Marvin was published early in 2014, only a few months before he passed away. It stands as a strong statement of the beliefs of a distinguished and internationally recognized physician, and reveals the passion for patient care that burned deeply within him.

The Journal of Clinical Hypertension

Marvin was the first editor of this Journal, which he started with the help of his friend, the publisher Louis Le Jacq. Later, the Journal became the property of its current publisher, Wiley. Right from the beginning the Journal was successful because it addressed itself to the clinical questions and uncertainties faced by practitioners in the field. Dr Moser worked to create a structure for the Journal in which a number of distinguished hypertension experts undertook to write columns that were educational in nature or which critiqued important new studies published elsewhere in the literature.

As an editor, Marvin Moser was scrupulously fair. For instance, even though he was personally supportive of the rather controversial conclusions of the widely publicized Antihypertensive and Lipid‐Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) and the JNC 7 report that soon followed it, he was fully amenable to one of us (MAW) publishing commentaries in his Journal that were in sharp contrast to Marvin's own views. One of Dr Moser's missions during his editorship was to form a relationship between the Journal and a major society, and in the end he achieved this goal when the Journal became an official journal of the American Society of Hypertension. For Marvin this was a very satisfying conclusion, and the relationship lasted for almost 10 years before the Journal became the official journal of the WHL.

At the time this Journal began in 1999, industry was still very much involved in the hypertension domain. In fact, the Journal at first depended on industry support and on reporting industry‐sponsored clinical trials, and so it is noteworthy that in just the few years since Dr Moser relinquished the helm of The Journal of Clinical Hypertension that industry support has greatly diminished. The reality is that very few pharmaceutical companies are now developing or marketing antihypertensive agents due to the wide availability of generic agents. Despite this, the Journal's reach and stature are growing more strongly than ever, a testament to the insistence on quality and relevance that began with Marvin.

After 10 years at its helm, Marvin stepped aside as Editor‐in Chief, but he showed no signs of slowing down. His passion for teaching hypertension never abated. Right to the end he headed up the philanthropic Hypertension Education Foundation. He established the Marvin Moser Clinical Hypertension Award of the American Society of Hypertension as a way of publicly recognizing those clinical scholars who most advanced the practice of hypertension. And, in a very relevant gift to his alma mater, the Downstate College of Medicine, Marvin endowed an annual lectureship that has brought leading experts in the field to share their knowledge with the faculty and students.

Despite the commitments of his 40 years of medical practice, his numerous teaching obligations and his powerful commitment to the NHBPEP, Marvin Moser was very much a family man. His relationship with his wife, Joy, who often accompanied him to major medical meetings, was one of deep affection and mutual respect. In fact, Marvin would happily acknowledge that he was not the only scholar in their home: Joy is a highly accomplished painter and still actively engaged as a Professor of Art and Education at Columbia University Teachers College. Marvin was devoted to his children and granddaughters, about whom––with a grandfather's unrestricted license––he would speak with great pride!

Those of us who had the privilege of knowing Marvin recognized that beyond his strong professional interests he surveyed national and world events with a keen and analytical interest. Incredibly, he found time for recreational activities: He loved playing golf, and until very recently was an active and competitive tennis player. To the delight of his friends, again reflecting Marvin's talent for the unusual, he agreed to serve as a model for advertisements for the clothing company Abercrombie & Fitch. As a distinguished and handsome man, Marvin added a great deal of patriarchal authority to the company's campaign while, at the same time, totally enjoying the humor and novelty of the situation.

A Last Note

If we had to summarize Marvin's career in a brief sentence, it would be to describe him as the ultimate public health activist for hypertension. True, he ran a very successful and highly regarded medical practice and contributed a great deal to medical research and educational endeavors. But, above all else, he was one of the major leaders in creating the field of hypertension and making it an intrinsic part of contemporary medical practice. Innumerable people in this country and around the world have lived longer and healthier lives because of Marvin Moser's vision and commitment.