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Transforming Conditions

The Example of North Karelia³⁷

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The successes of the North Karelia Project in Finland—in which heart disease, stroke, lung cancer, and other noncommunicable diseases declined dramatically over several decades—are legendary within the public health field (Puska, 1995, 2002). Both students and veterans of public health history are familiar with the project’s steeply pitched graphs (for example, Figure 13) and the general outlines of the story of how a dedicated group of Finns transformed the eating and smoking habits of an entire generation (Vartiainen, Jousilahti, Alfthan, et.al., 2000). The achievements in North Karelia are a source of optimism and envy in the United States, where health protection efforts over the same time period did not yield results anywhere near as dramatic, comprehensive, nor sustained as these (Hancock, Sanson Fisher, Redman, et.al., 1997).

Figure 13: Coronary Heart Disease Mortality Rates in Finland and in the North Karelia Region, per 100,000, Men Ages 34-65, 1967–2001

The North Karelia Project deserves its reputation, but the story is in fact more complicated and interesting than its common depiction as a successful community-level behavioral change venture. In fact, the events in North Karelia exhibit several innovations that are prototypical of a syndemic orientation, although the project began long before that word was even imagined. The distinctive approach used in North Karelia sprang from some of the same sources that we have examined earlier: a strong sense of place, intense concern that residents of that place were unnecessarily vulnerable to multiple afflictions, a passion for redirecting health futures in jeopardy, and an unwavering attention to relationships among people, problems, and the possibilities for change. These features, in turn, led to public actions that simultaneously strengthened people’s power, expanded people’s choices, instituted norms of widespread accountability, and ultimately transformed adverse living conditions along with the health indices that they engender. When viewed through a syndemic macroscope, the success of the North Karelia Project is awe-inspiring, but it does not seem peculiar to Finnish culture as some contend. It seems, instead, to be the well-earned result of concerned, humane, directed work, informed by pragmatic ecological thinking about the relationship between people and places.

Launching a Cultural Movement for Health
The origins of the North Karelia Project go back to an epidemiological study in the late 1960s, which compared the health status of residents of Eastern and Western Finland with that of other populations around the world. The study concluded that Finnish men between the ages of 30 and 59—particularly those in the North Karelia region—had the highest rates of heart disease mortality in the world. At the time, our understanding of cardiovascular risk factors was just beginning to take shape. The prevailing wisdom suggested that the high rate of disease was tied to Finnish propensities for smoking, eating high-fat foods, and being less physically active than their counterparts elsewhere—all of which were especially true of the dairy farmers in North Karelia. Clinicians and public health researchers were understandably alarmed by these findings. Less predictable was the reaction of the citizenry in general. Soon after the results were announced, a group of civic leaders grew so angered by the health crisis that they petitioned the Finnish government for assistance in organizing some kind of response.

This early interaction among physicians, researchers, and impassioned citizens is an important feature of the North Karelia story. The initial impetus for action came not only from epidemiological evidence, but equally from the hearts of those with roots in the region who were active in its public life.³⁸

The Finns rejected the notion that heart disease and other chronic illnesses are problems only for those at highest risk. Even those with low and moderate levels of risk still develop these afflictions, albeit at a lower rate. With many more people in the middle area of the risk distribution compared with those in the high risk tail, helping everyone to change even a bit promises large effects for the population as a whole. Following Geoffrey Rose’s strategy of population-based preventive medicine (Rose, 1992), leaders of the North Karelia Project regarded their high mortality rate as a signal that the entire distribution of risk across the population had to be shifted. They did not set out to improve the health of particular people, but rather to assure safer, healthier conditions in Finland itself.

There were no illusions that such large-scale change would come easily. Individuals would ultimately have to put forth the effort to alter their own risk behaviors. However, the architects of the North Karelia Project understood that organized public work ventures could substantially ease the burdens, increase the rewards, and expand the freedoms for all people to stop smoking, improve their diet, boost their level of physical activity, and make other health-related changes (Figure 14; adapted from: Puska P. North Karelia International Visitors’ Program, 2003).

Figure 14: Public Work Enhances Individual Effort

The project’s approach was firmly rooted in behavioral theory and health planning models (McAlister, Puska, Salonen, et.al., 1982; Puska, 1995). These conceptual frameworks provided a stable set of concepts for guiding the project, even as it evolved over several tumultuous decades. Part of that flexibility was due to the project’s open approach to action planning, constantly inviting creative contributions from those outside the core project team. The health crisis affected everyone in the entire population, either directly or indirectly, and so the call to contribute spread throughout the region. Given this orientation, the researchers made a crucial decision in their evaluation planning. Instead of adhering to a single, inflexible intervention protocol, a more comprehensive, ecological strategy was framed around the pragmatic principle that any number of actions may be introduced by any number of actors, either simultaneously or in sequence. Whatever sense of control the project leaders may have relinquished in taking this stance (if any at all) was offset by their conviction that massive citizen effort was necessary to spread and cement the changes they sought.

There is no doubt that the talents and persistence of world-class health professionals were crucial to the project’s success. But the engagement of ordinary citizens who felt connected to and angered by the tragedy of so many early deaths galvanized the entire effort, transforming it from an ad hoc disease prevention project into a serious cultural movement for better health that continues even today. Those citizens who launched the North Karelia Project pushed for recognition from their elected officials, while also holding themselves accountable by devoting their own time, energy, and talents to the work.

Many creative innovations were devised not by experts with technical training in health care or public health, but rather by citizens who were moved to ask themselves, “What can I do to make it easier for people in North Karelia to be healthy?” To that straightforward question came an array of astonishing answers. Bakers devised lower-fat loaves, working for years to perfect breads that had less salt, more fiber, and still pleased their customers’ palates. Sausage makers added mushrooms to their products to increase vegetable consumption. A food scientist at the University of Helsinki discovered a breakthrough way to lower cholesterol in margarine and immediately approached the dairy and margarine industries so that they could incorporate his discovery.

Each of these examples illustrates the ecological thinking and public-spirited orientation that animated the project. Over the years, people from many walks of life found ways of applying their particular skills and talents to the health issues before them, whether or not health was seen as falling within their scope of responsibility. No one directed the baker, sausage maker, and food scientist to pursue innovations that would make it easier for their fellow citizens to eat more healthfully, but they did. They regarded the entire population’s health as a goal worthy of their own work—now newly understood as public work—with themselves, their families, and their nation as beneficiaries.

Identifying and Fighting Afflictions
The project was organized initially to respond to excessive heart disease deaths. It later expanded to address a constellation of other interrelated afflictions such as stroke, diabetes, cancers, alcohol use, depression, and others. In the late 1960s and early 1970s, the initial focus on smoking, high-fat diets, and physical activity was something of a leap of faith. These risk factors, while clearly viable suspects for heart disease (and other chronic illnesses), were by no means supported by the body of evidence that exists today.³⁹

One early decision in the education realm was to avoid over-complicating the messages from the project to the public. Instead of a deluge of detail on fat content, lipids, blocked arteries, and the like, messages emphasized that people had choices to make about their consumption of food and tobacco and their willingness to become more physically active. The project team’s goals were to make at least some of the difficult choices easier for people and to reward them when they did make healthier choices.

They were aided tremendously in these efforts by several unique features of Finnish society: an advanced welfare state with universal access to health care services and a rate of newspaper readership approaching 100%. Communicating with the population directly through news articles, editorials, and letters to the editor was a valuable and extremely effective tool in Finland, one that the North Karelia Project used to the fullest.

Examining Living Conditions and Crafting System-wide Change
The people of North Karelia used a combination of individual action and collective political organizing to change the conditions in which they were living—conditions that they were beginning to see as lethal. Tobacco consumption was curtailed through legislative means (e.g., taxation, restricting the places where one could smoke), food labeling requirements were changed (e.g., forcing manufacturers to specify not only low-salt or low-fat content, but also high-salt and high-fat as well), and entire industries were shifted. Within the dairy industry, low-fat milk and cheese production increased to the point where, in 2002, a 5%-fat cheese won a food industry award for best new product and was sold out for weeks. Berry farming and consumption were also promoted to make up for declining dairy revenue, in part by convincing the Finnish Army to offer local berry juice in its food services to stimulate demand for the berry farmers’ products.

Naturally, these achievements were not won without engaging those individuals and institutions whose cultural, economic, and political interests were threatened by the prospect of change. The dairy industry, for example, was not only an important part of the economy, but represented a culturally resonant way of life for generations of Finnish families. High-fat eating habits, such as lavishly buttering bread and consuming cream and rich cheeses at every meal, were a deeply entrenched source of enjoyment, ritual, and pride. Finland even had laws on the books—promoted by the dairy industry—that banned the mixing of butter and oil. Eventually, through the deliberate work of the project, these high-fat eating habits came to be seen in a new light. And the law that prohibited adding oil to butter was eventually overturned in the wake of massive kitchen disobedience among thousands of housewives who believed that some dilution could be tolerated in the name of their families’ and the nation’s health. Cultural pride, in this case, was transformed from obstacle to strength, as it fueled the public work that literally redirected the lines on the heart disease charts.

Building the Power to Act and Guiding Social Change
Looking back from our vantage point today, it is easy to see how much public strength was already present when the citizens of North Karelia wrote their petition and began organizing a serious response. They were outraged, but in a constructive way: willing to pitch in, to confront people who may disagree, and to work out viable solutions. They had dedicated allies in the clinical realm who found ways of guiding and educating without interfering or dissipating people’s passion for change. Everyone—politicians, physicians, bakers, schoolteachers, dairy farmers—read the newspapers, which in turn featured daily information and frank exchanges about what the North Karelia Project and its supporters truly value along with the perspectives of those who disagree. Despite their different interests—or rather by working in and through them—the Finnish people came to see a very different future from the one on the immediate horizon and they chose to move in a safer, healthier direction.

In the United States, we view this display of civil, democratic work with envy, recognizing that it gave the Finns a significant advantage in their struggle to improve adverse living conditions. Instead of depleting their reserves of this potent elixir, their endeavors to redirect the course change only built more public strength.

More recently, however, these same Finnish newspapers have been calling for a “New North Karelia Project” to focus on alcohol and problems facing youth. Whereas many threats of the last century have been brought under control, the modern globalizing world is now presenting a new list of afflictions and conditions to concern North Karelians: cheap liquor imports from Estonia, high-tech desk jobs curtailing physical activity, increased smoking rates among teenagers and women, as well as growing rates of injection drug use, suicide, and depression. These are more difficult problems to address, less amenable to the “simple message” strategy that worked so well for diet-related risk factors. Whether the relationships and public strength built so effectively during the project’s first three decades can adapt to these new challenges is an unfolding and fascinating question.

Viewed through a syndemic orientation, the need for intense, place-based, public health work in North Karelia—and in all regions of the world—will continue ad infinitum. Our efforts to assure healthful conditions remain constant, but the challenges to be met and the horizons to be explored change with the constant flow of time and endless stream of physical and social evolution. As navigators in this epic journey, one of our most valuable skills is the ability to anticipate change, so it is to that task that we now turn.
 

37. This section was informed greatly by participating in August 2003 in the week-long North Karelia International Visitors’ Programme (National Public Health Institute, 2003). Visiting Helsinki, Joensuu, Ilomantsi, and other towns where the project began–and where it remains very much alive today–provides insights that are not contained even in the voluminous publications by and about the project. Thanks to the openness of the research team in Helsinki (led by Erkki Vartiainen, Aulikki Nissinen, and Pekka Puska) and the practical intervention team in Joensuu (led by Vesa Korpelainen), we visitors had an opportunity to speak directly with the bakers, newspaper publishers, food scientists, school teachers, berry farmers, restauranteurs, elected officials, entrepreneurs, physicians, housewives, grocers, and others whose work made the project so unique and successful.

38. Among those early leaders, Pekka Puska emerged as a central figure. A young doctor with familial ties to North Karelia, Puska proved tremendously insightful and effective in organizing the initial demonstration project. He quickly became the scientific lead for the project, and later was elected to represent the region in Parliament. In 2000, with decades of experience leading the Finnish effort, Puska became Director General of the National Public Health Institute in Finland (KTL). He was also called upon by the World Health Organization to lead their health promotion and chronic disease prevention operations from 2001-2003.

39. Results published by the Finnish researchers, in fact, provided some of the strongest evidence available about cardiovascular disease and other chronic illnesses.

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Page last reviewed: January 30, 2008
Page last modified: January 30, 2008

Content source: Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion