North Karelia Project – An unrepeatable success story in public health

A few decades ago in eastern Finland, a dramatic reduction in the cardiovascular disease mortality rate was achieved through special circumstances: the same would not have worked elsewhere, nor would such a project gain similar success in contemporary Finland.

In the 1970s, cardiovascular diseases were more prevalent in Finland – particularly in eastern Finland – than in other countries. Public officials came to the conclusion that too many citizens were dying of heart attacks and decided to fight the risk factors. An experiment named after the eastern province of North Karelia was launched.

“The North Karelia Project, carried out from 1972 to 1995, was an immense health policy intervention,” summarises Johannes Kananen, a university lecturer in social work at the University of Helsinki.

The North Karelia Project is often presented as an international success story that progressed linearly from its commencement to the analysis of results. The further the project progressed, the lower the mortality rate related to cardiovascular diseases fell.

In addition to describing the results, Kananen wishes to highlight how the North Karelia Project defined the concept of public health both in Finland and beyond. According to him, awareness of this background is important also for introducing new perspectives in the current debate on social welfare and health care.

At the moment, Finland is witnessing the most extensive reform of public administration, and social welfare and health care services in the country’s history. The intention is to transfer the responsibility for providing social welfare and health care services from municipalities to 18 new counties to be established under the reform. The Act on Clients’ Freedom of Choice, drafted as a separate project, would enable people to freely choose between services produced by a county, a private company or an organisation.

Notion of collective health as a result of the project

The success of the North Karelia Project was the sum of many overlapping factors.

Firstly, the project succeeded in scientifically determining the cardiovascular risk factors increasing the mortality rate in eastern Finland, the top two being smoking and fatty food.

Secondly, an administrative hierarchy was established in Finland in conjunction with the North Karelia Project as health centres began operating during the 1970s, bringing health experts and physicians, as well as state and municipal administrations together. Thus, the project was implemented in an exceptionally broad manner by almost all fields and levels of the public sector. The project was led by the National Board of Health, the predecessor of the National Institute for Health and Welfare.

"The North Karelia Project contributed to the definition of ‘public health’ in Finland."

In the region of North Karelia, a social and ideological movement that engaged local citizens in the project’s objectives was successfully established.

The result was a tradition where health experts determine the actual needs of the people, while people came to view their personal needs increasingly through the prism of scientific definitions.

“The North Karelia Project contributed to the definition of ‘public health’ in Finland. According to its premise, there are certain diseases of public-health importance, in this case cardiovascular diseases, which demand collective measures. Experts determined the measures required by peoples’ health and diseases, generating a hierarchical system that was managed from top down,” says Kananen.

The success of the North Karelia Project is based on all of the above conditions being in perfect alignment. Therefore, Kananen believes corresponding projects would not work elsewhere.

North Karelia Project as the reality television of the 1980s

The North Karelia Project’s objective was to make the region’s inhabitant smoke less and eat healthier food. This was transformed into a national public-health project.

“The measures taken were varied, with an enormous public information campaign launched by the government.”

To make people change their behaviour, the risk factors were publicised. Training events were organised in partnership with non-governmental organisations. The Martha Organization, which promotes the wellbeing of homes and families and the appreciation of household economics, taught North Karelian women to cook traditional meals in a healthier way. In schools, pupils took part in health projects and wrote compositions on health subjects.

In the vein of today’s reality television, there were weight-loss shows already in the 1980s where the blood and cholesterol values of dieting participants were measured.

Stickers spreading the gospel of the North Karelia Project were plastered across bus windows and other surfaces. Public messages like these created a moral pressure to join in the project.

“The movement was managed from top down, engaging both society and individuals. The project engendered a kind of regional pride and sense of community in North Karelia. We have those to thank for the project’s success,” says Kananen.

“At the same time, the project helped in defining the difference between the actual needs of the population and the needs experienced by people themselves.”

The actual needs were determined from the top on the basis of scientific criteria. The government aimed to make citizens aware of their real needs, while citizens were granted equal access to care, which is a central principle of the welfare state.

Freedom of choice in its infancy

Compared with the thinking in the 1970s, the debate on the freedom of choice related to today’s social welfare and health care reform may seem radical. Four decades ago, the health of the nation was for the most part prioritised ahead of the health of the individual, who was expected to observe guidelines set by the government.

In the age of the current ideology, which puts the emphasis on individualism, governmental health interventions similar to the North Karelia Project are no longer possible, claims Kananen.

“In the 1970s, political choices were about the scope of health care provided for people, whereas the individual freedom of choice primarily meant whether you were a smoker or a non-smoker. There were no other types of alternatives.

Even though freedom of choice is the topic of the day, the social welfare and health care reform has been founded on the legacy of the North Karelia Project and a collective mind-set, says Kananen.

“On a scale of 0–100, our freedom of choice is currently around one or two. Freedom of choice granted to individuals is something so new that we still don’t quite understand what it actually entails.”

In the field of social welfare and health care, individual freedom of choice has so far been viewed only as broad choices, such as cutting down drinking or smoking. Even under the current social welfare and health care reform, freedom of choice is the freedom to choose between privately or publicly produced care, a pretty rough categorisation in itself. There has been no discussion on making subtler choices.

What is freedom of choice in terms of health?

A peculiar tension is present in the relationship between public health and democracy. According to the ideology of democracy, decisions must be made by the people, but from the viewpoint of science, there is only one true way to healthy living, notes Kananen.

Kananen believes that the current debate on freedom of choice is missing the opinion of health authorities on whether there is such a thing as individual health: people making personal choices that improve their health, as well as certain lifestyles being seemingly better suited to some than others.

"When discussing freedom of choice, we should also consider what that freedom means."

“Food and health choices are, more than anything, individual choices. Yet, the authorities have not held discussions about the kind of knowledge on which personal health choices should be based. In science, there is no room for such debate, since health sciences are looking for unequivocal health criteria.”

For example, official recommended dietary allowances are made for the entire nation, taking into consideration changing public health diseases and cultural dietary habits.

Today, the debate on individual health choices starts from the ground up. People are looking for individual diets, not necessarily based on science, and official health recommendations are being questioned.

Kananen demands alternative scientific perspectives on health and wellbeing. They are needed for people to make better personal decisions based on scientific research.

“When discussing freedom of choice, we should also consider what that freedom means. Do we want more freedom? What decisions should be left to people themselves? If we genuinely wish to increase peoples’ freedom of choice in the field of social welfare and health care, we also need structures that will support them in the choices they make. This discussion is yet to be had.”

Conceptualising public health

Johannes Kananen is a university lecturer in social work at the Swedish School of Social Science of the University of Helsinki and a docent of social and public policy.

Together with Sophy Bergenheim and Merle Wessel, Kananen has edited the recently published book Conceptualising Public Health – Historical and Contemporary Struggles over Key Concepts (Routledge).