In 1972, an international team of academics identified a new and terrifying public-health crisis. In a far eastern province of Finland—North Karelia—middle-aged men were dropping dead of heart attacks at the highest known rates in the world. Until then, public-health officials focused on infectious disease like flu epidemics and polio; if someone died of a heart attack, it was an untimely consequence of old age. The Finnish Minster of Health at the time recognized the novelty of the problem and appointed a 27-year old physician with a master's degree in social sciences, named Pekka Puska, to lead a pilot project in the region to tackle the problem. Not because he was good, but because he was young and the problem was going to take a long time to solve. He made the right choice. In the ensuing decades, Puska pioneered a strategy that lowered male cardiovascular mortality in a population of 170,000 Finns by some 80 percent—an unparalleled accomplishment. And he achieved it by breaking established rules of public health.
When Puska began his career in public health, the first international studies were showing that diet and smoking were somehow connected to heart disease. Ancel Keys, a University of Minnesota physiologist, had been promoting his hypothesis—controversial at the time and still attacked by some today—about the association between eating animal prdioducts and heart disease. (Tobacco was already a well-known culprit.)
In what would become known as the Seven Countries Study, Keys, the epidemiologist Henry Blackburn, and their colleagues recruited groups of middle-aged men for a long-term project not only in Finland, but also in the United States, Japan, Italy, the Netherlands, Greece, and Yugoslavia. Each subject in the study was asked questions about his diet and given a battery of physical tests. Duplicates of everything they ate were collected, frozen, and sent to a University of Minnesota lab for analysis. Then, at five-year intervals, the study checked in on the subjects again. A pattern soon emerged: The farther north the men lived, the more animal products they consumed and the more heart attacks they suffered. In Greece and Italy, where people ate mostly a plant-based diet, men were largely free of heart disease—an observation that eventually informed our understanding of the value of the traditional Mediterranean diet. (Keys has been criticized for omitting government data on diet and heart disease from certain countries that he compared early on. But Keys had good reason to leave out the data: Death certificates were undependable, and World War II had disrupted the food supply in those countries.) In places like North Karelia (the study’s northern extreme), conversely, men were 30 times more likely to die of heart attacks than in places like Crete. In fact, North Karelian men on average were dying 10 years earlier than their counterparts in the south. It got so bad that, by 1972, North Karelian men achieved the dubious distinction of having the highest rate of heart attacks in the world.
To Puska and the researchers, the roots of the disease were clear. Before World War II, North Karelian men were largely lumberjacks whose diets revolved around hunting game, picking berries, and fishing. Besides the occasional bear mauling, their main health concerns were tuberculosis, infectious diseases, and death at childbirth. After the war, veterans, as part of their compensation, were given small plots of land. Lacking agriculture skills, they cleared the land to raise pigs and cows. Predictably, pork and diary consumption skyrocketed. Butter soon made its way into almost every meal: butter-fried potatoes, buttered bread. Even traditional fish stew was half butter. They had fried pork or meat stew for dinner, chased with buttered bread and milk. Vegetables were considered food for the animals. Adding to the problem, GIs had returned home with a new habit: By 1972, more than half of all men smoked.
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I interviewed Puska in his Helsinki office on a cold June afternoon not long ago. He had recently retired as the director of noncommunicable-disease prevention for the World Health Organization; wall photos of him with heads of state and diplomas recorded a stellar career. “In my wild youth I was very active in student politics,” he told me, gesturing expansively. Now 68 years old, he looked decidedly non-wild, wearing a bureaucrat’s khaki pants and crooked knit tie, but still retained Steve McQueen good looks with limpid blue eyes and sandy brown hair. “That was the time for thinking you could change the world.”
When he first arrived in Joensuu, North Karelia’s capital, instead of hiring seasoned public-health workers, he organized a team of like-minded idealistic young people. He consulted Geoffrey Rose, a British epidemiologist who argued statistically that it was more cost-effective to prevent disease than to cure it. In Rose’s opinion, hospitals and doctors could no more solve the problem of general ill health than famine relief could solve the problem of world hunger. He was the first to show, using epidemiological data, that the number of people who died of heart disease was directly proportional to the average blood-pressure levels of the whole population. He also calculated that for every percentage point you lowered cholesterol in a population, you lowered heart disease by two points. Whether you lived a short, sick life or a long, healthy one, Rose argued, was a function of the population you belonged to more than the quality of your doctor or hospital care. Puska applied Rose’s thinking to public health. “I could see the whole system needed to change,” he said. He shifted the focus from trying to change individuals to improving the physical and social environment.
Puska and his team approached the Martha Organization, a powerful women’s organization with several local clubs, to help spread the word. Together, Puska and the clubs hatched the idea of holding afternoon “longevity parties,” where a member of Puska’s team would give a short talk encouraging them to replace butter with oil, meat with vegetables, cut salt, and stop smoking. They gave the women a recipe book that added vegetables to traditional North Karelian dishes and cooked and served them. North Karelian stew, for instance, typically had only three main ingredients—water, fatty pork, and salt—but the team replaced some of the pork with rutabagas, potatoes, and carrots. The women liked the new version of the dish, which they named “Puska’s stew.” By showing these women how to cook plant-based meals that tasted good, Puska had found a way to disseminate the health message better than any leaflet could.
Inspired by a former professor, Everett Rogers, who came up with the idea of “opinion leaders,” Puska next went from village to village recruiting “lay ambassadors.” Believing that the best way to spark cultural change was from the bottom up, he recruited some 1,500 people, usually women who were already involved in other civic organizations. He gave each ambassador an identification card, taught them simple messages about reducing salt and animal products, and encouraged them to talk to their friends.
His small, underfunded staff tried everything they could think of to infiltrate the community. Puska spoke relentlessly at churches, community centers, and schools. He became the face of this new health movement, constantly recruiting people to the cause. (One of his mentors once told him that the only way to succeed in prevention is to “push, push, push.” His English-speaking friends later joked, “Now we know why your name is Puska!”)
Next, Puska started to lobby food producers. You could have the world’s best program to educate people about how to eat healthier, he figured, but if they weren’t able to obtain healthy ingredients, then what good was it? The regional sausage company, for example, loaded its products with pork fat and salt. Traditional breads were laced with butter. Karelian cows, developed from breeds known as Finncattle, produced some of the fattiest milk in the world, and dairy subsidies rewarded high fat content.
At first, none of the businesses were interested in formulating healthier versions of their products. Why should they risk their profits? In fact, the powerful dairy industry fought back, taking out ads bashing the project. But the ads backfired, because they sparked a public debate, raising the question of the connection between dairy and heart disease.
North Karelians were also realizing that they needed to eat more fruits, but common fruits such as oranges or melons were expensive. They had to be imported from southern Europe, and they played no part in the Karelians’ traditional diet. Puska saw a homegrown solution: berries.
During the summer, blueberries, raspberries, and lingberries grew abundantly in the region, and North Karelians loved them. But they ate them only in the late summer, during the short berry season. So Puska’s team supported the establishment of cooperatives and businesses to freeze, process, and distribute berries. They convinced local dairy farmers to apportion some of their pastureland to grow berries and convinced grocers to stock frozen berries. As soon as berries became available year-round, fruit consumption soared.
North Karelians love their pork sausage and Puska understood he was not about to get people to give it up. So, he appealed to the regional sausage maker to gradually reduce salt and replace pork fat with a filler made from local mushrooms. Customers didn’t even notice the difference. In fact, sausage sales actually increased.
The project also successfully took aim at smoking. It convinced workplaces and legislators to adopt smoke-free policies. They provided smoking-cessation programs and then they pitted villages against each other in contests to see which could achieve the most participation.
Looking back 25 years, Puska’s project produced impressive results. Smoking rates dropped to from 52 to 31 percent. The mortality rate of coronary heart disease in the middle-aged male population in North Karelia has reduced by about 73 percent. Life expectancy for men rose by seven years, and for women, six years.
Even so, some academics criticized Puska because they said it was impossible to pinpoint exactly what had caused the improving numbers. Was it the drop in meat consumption? The rise in vegetable and fruit consumption? A rising health awareness among the general public? Perhaps the lay ambassadors created more social equity among these otherwise taciturn Finns? His medical colleagues ridiculed the project, calling it “shotgun medicine.” But Puska’s strategy worked: He may have fired a shotgun, but he unleashed a healthy blast of silver buckshot that saved lives.
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After meeting Puska in his office, I visited North Karelia to see how this program had transformed people’s lives. I boarded a train in Helsinki and traveled 250 miles north, passing through boreal forests and pea-green fields that swooped and curved like curlicues on a paisley shirt. Homesteads dotted the landscape—cozy, compact houses painted bright red or burnt yellow, with medieval-looking plank barns out back. When I arrived in Joensuu, the sun was arcing low over the Scandinavian sky. A brassy light illuminated the city’s birch-lined streets, lakefront houses, and Lutheran churches.
I found the headquarters of the North Karelia Project on the sixth floor of a brick building that fronted the town plaza. It was a cramped jumble of four small offices furnished with Ikea-style desks and lined with 30 years of records in neat file folders. There, I met Vesa Korpelainen, a tall, serious man with sandy brown hair, blue jeans, and a red-checkered shirt. Since 1986, he’d been Puska’s man on the ground in North Karelia. He told me how he motivated his team.
“We have two slogans that drive our work,” he said. “‘Face-to-face communication’ and ‘common interest.’ It’s extremely important to get people involved. That means you have to be honest. You have to work with people—on the same level.” He described his team’s daily activities as “meetings, meetings, meetings,” and he attributed their success to a “relentless, congenial nudging” rather than any heroic initiatives.
As I listened to Korpelainen, the various pieces of the North Karelia campaign began to come together in my mind. Partly through trial and error, but also through tremendous dedication and persistence, Puska and his team had developed a winning strategy.
To show me how these strategies had been put into practice in the capital, Korpelainen took me on a walking tour of Joensuu. We first visited a grocery store, where he pointed out products inspired by the project: rows of healthy butter substitutes and candies sweetened with xylitol, a sweetener made from birch sap. In an open market we saw row after row of berry and wild-mushroom vendors. There were only two holdouts from the old dietary regime: One vendor sold butter-fried smelt; another offered pocket pastries filled with rice porridge and about a half stick of butter each. After that we breezed through a restaurant and saw the prominent salad bar. Soft drinks were served in small glasses and customers paid for refills.
Outside of Joensuu, I met a couple in couple in their 90s, Mauno and Helka Lempinen. Mauno, a woodcutter, was splitting wood when I arrived. They invited me into their cottage for a lunch of rye bread and vegetable soup, garnished with cucumbers and tomatoes. The couple recounted how they had come to North Karelia in 1973 and soon adopted the local diet. They started their day with buttered bread and coffee, lunched on cold-cut sandwiches, and dined on pork stew.
In 1983 Mauno suffered a heart attack. Emergency open-heart surgery saved his life. I asked how that had altered their lifestyle, expecting a long list of healthy adjustments. “Oh, we didn’t change anything.” Helka said.
“Since when did you start eating vegetable soup?” I asked.
Helka looked down and thought hard. She had no idea. “It just happened,” Mauno said finally. “But I guess it saved my life.” It occurred to me that this comment summed up the whole North Karelia Project: It had changed people’s lifestyle, without them realizing it.
The North Karelia campaign had tackled the region’s health problem from so many different directions, its reforms were all but invisible. They’d simply changed the environment. Here was a rural community in far-flung Finland that had made deliberate decisions, changed its diet and habits, adapted to its traditions, and improved its people’s health. A small Finnish region is one thing—could this sort of transformation take place in 21st-century America?
Four the past five years, my colleagues with the Blue Zones Project and I have taken a similar system-wide approach to health in 23 American cities. We’ve seen decreases in smoking, obesity, and healthcare costs for city workers by combing influence in a city: The mayor, city manager, chamber of commerce, local CEOs, health department, restaurant association, and school superintendent all need to understand—and endorse—approaches to improving the health of a community. We help city planners envision streets design for people–not just cars. We introduce tax-neutral polices and show communities how to make their streets safer, more walkable, and more bikeable. The average American burns fewer than 100 calories a day engaged in exercise, yet according to the Robert Wood Johnson Foundation, you can raise the activity level of an entire city by up to 30 percent with designs that favor the pedestrian and bicyclist.
In America, the economics of health—for doctors, hospitals, and pharmaceutical companies—largely rely on people getting sick. From Puska’s North Karelia experiment, we learn that designing for health can yield powerful and measurable returns. The trick is to design an environment that helps make the right decisions for us, making the healthy choice not only easy, but unavoidable.