Will social determinants reshape pediatrics? Upstream clinical prevention efforts past, present, and future

In the early 1960s when Dr. William Kannel, Director of the Framingham Heart Study, first coined the term “risk factor”, most physicians considered it outlandish to screen patients for predictors of disease risk to guide their interventions. Despite the fact that heart attack and stroke cut short hundreds of thousands of lives every year, at the time, little was known about how cardiac disease precursors could be used to guide effective upstream prevention. But Dr. Kannel had studied the epidemiology of cardiovascular disease for years, establishing clear links between novel risk factors like hypertension, hyperlipidemia, and smoking and subsequent heart attack and stroke. Based on this early evidence, his logical (yet radical for the time) recommendation was that clinicians should screen for and intervene upon upstream risk factors in addition to managing downstream manifestations of cardiovascular disease.