Dr. Balaguer, the renowned cardiologist, has died at the age of 88 years, after a long life full of great personal and professional satisfactions.
Before writing about his professional activity, we wish to express our condolences to his wife, Conchi, and his children. His death is a tremendous loss not only to Spanish cardiology, but also to international cardiovascular epidemiology.
The authors of this obituary represent two generations of students and colleagues privileged to have known and to have worked closely with Dr. Balaguer. Firstly, we must first mention his outstanding work in setting up and developing the School of Cardiology and, secondly, his vision of the future, which led him to carry out pioneering epidemiological research in Spain, for which he became internationally renowned.
Antoni Bayés de Luna writes: when I started work at the School of Cardiology at the University of Barcelona, it had recently been founded by four young cardiologists: Drs. Torner, Balaguer, Gregorich, and Morato, with the academic and institutional support of Prof. Gibert Queralto. The School was situated in the basement of the formar Hospital Clínic de Barcelona and consisted of approximately 100 m2. In each corner, there was a dispensary for each of the young doctors and, in the middle, a space for X-rays and a primitive cardiac catheterization room. It was 1959, electrocardiography was only just beginning, and—obviously—the only imaging technique was radiology.
At that time, the physicians who knew how to auscultate were cardiologists, and these four specialists were absolute masters of this technique. Rheumatic heart diseases were the big thing and were beginning to be treated surgically, while interest had already arisen in congenital heart diseases, in which Dr. Torner was a great expert. A short while later, Dr. Casellas arrived from Mexico's National Institute of Cardiology, with new ideas on the exciting possibilities offered by modern electrocardiography, which he had largely developed in that center. During those years, the School was the leading institution for Catalan cardiology and its reputation spread throughout Spain and Latin America.
In this propitious environment, Dr. Balaguer intuited that ischemic cardiology would be the wave of the future and he had already begun to show interest in clinical and therapeutic aspects of this disease, although his main interest lay in its epidemiology, in which he was a real pioneer. At the beginning of the 1970s, nobody was showing much interest in a disease that was believed to be untreatable and unpreventable. Risk factors were hardly mentioned and nonsmokers were considered old-fashioned reactionaries. He had the foresight to realize that ischemic heart disease would be the plague of the immediate future and that identifying its risk factors would be essential for the treatment and prevention of coronary arteriosclerosis. This facet of Dr. Balaguer's work will be described in greater depth below by his closest colleague, Luis Tomás Abadal.
Dr. Balaguer was an excellent president of the Spanish Society of Cardiology and increased its international prominence, especially through joint cardiovascular prevention campaigns with the World Health Organization. He was also a staunch defender of the interests of cardiology in general and of coronary care units in particular.
For my part, I can only say that I always admired him and, beneath his serious exterior, I found not only a mentor who helped me when I went to England and on my return—at a time which such adventures were difficult—but who was also a friend, from whom I was always ready to learn and who I was always prepared to help. As president of the World Federation of Cardiology, I asked the recently retired Dr. Balaguer, together with Prof. Chockalingan from Canada, to edit a White Book on cardiovascular health. I was able to witness his characteristic scientific rigor, tremendous capacity for hard work, excellent writing skills, and his enormous satisfaction when the book was finished. In the copy presented to me by my friends and colleagues, he wrote me words full of tenderness, appreciation, and affection. I will never forget it.
Luis Tomás Abadal writes: I met Dr. Balaguer in 1964, when I graduated from the Faculty of Medicine of Barcelona, having decided to specialize in cardiology. Because of its prestige and the good reports I had received, I chose to go to the School of Cardiology. It was there that I met Dr. Balaguer, who at that time was the head of the ischemic heart disease and atherosclerosis outpatient clinic. He gave me my first lessons in this disease and I never stopped learning while at his side. I have to say that Dr. Balaguer taught me much more than cardiology. He taught me how to be a physician. I learned to be critical, rigorous and scrupulously honest, seeking the truth to help the patient. In a nutshell, he taught me the science and art of medicine, which begins with being able to communicate with the patient and accept—and attempt to alleviate—suffering.
Among Dr. Balanguer's qualities was his deep humanity, capacity for hard work, and honesty. As the sensible person he was, he had a singular capacity to understand and accept other people. I never heard him make a derogatory or disparaging remark about anyone.
Dr. Balaguer’ scientific merit was well known both in Spain and in international cardiology forums. He was a pioneer in many fields of cardiology, especially epidemiology and cardiovascular prevention.
I have had the privilege of collaborating with Dr. Balaguer in many projects that he undertook with commitment and courage, often without resources, his enthusiasm making up for the shortfalls.
In 1968, I was devoting my professional life mainly to occupational medicine and was following up a homogeneous population in a large company with more than 2,000 workers. It occurred to me that we could take advantage of the situation to conduct a prospective, observational, follow-up study in the working environment to record and identify the incidence of coronary disease in this population and its possible relationship with so-called cardiovascular risk factors. Almost 50 years after it was started, this study continues to provide useful information.
As the science that studies disease in specific populations, epidemiology does not require “cases” but rather “populations” or homogeneous groups that can be easily followed up. Companies are an ideal environment for this task. Dr. Balaguer, who worked in an eminently clinical environment—as was usually the case in his time—saw the need to use epidemiology to develop cardiology in Spain. He was prepared to sacrifice brilliance in clinical diagnosis in exchange for learning to manage data and understand what statistics can tell us. His great merit, in my opinion, was to humbly return to his origins to learn something he didn’t know. In short, he accepted being at the bottom of the class, when his place was at the top. He knew that was his role at that time. If only there were more men and women in Spain like that, always able and willing to begin again, to learn and transmit knowledge humbly and effectively.
Thanks to Dr. Balaguer, data on the frequency of cardiovascular diseases in Spain began to be known internationally. Due to his efforts and tenacity, Spain was included in the WHO Factories study and the MONICA (Multinational MONItoring of trends and determinants in CArdiovascular disease) trial. These studies were continued in Spain because of his foresight and perseverance, qualities he transmitted to the working group he headed during these years. In addition to being a tireless worker, he was a prolific writer, as shown by the huge number of review articles and original studies he published on cardiovascular epidemiology. His book, Preventive Cardiology, was used as a textbook for medical students in the 1970s and 1980s in Spanish medical schools.
Dr. Balaguer's capacity for hard work was admirable. I never saw him tired or disheartened. He rarely refused to participate in a cardiology meeting or congress and his scientific training and authority were always in evidence. His opinion was respected and admired. Dr. Balaguer's name was always came up whenever epidemiology and cardiovascular prevention were spoken of in Spain. His memory is alive in all those who knew him and will continue to be so for many years to come.
Beloved maestro, you have been a role model for us and for many other cardiologists. We will never forget you.