When North Karelian residents discovered that their population was distinguished by health problems, they became indignant. The government responded by approving a small grant and tapping Pekka Puska, then 27, with a medical degree and a master’s in social sciences, to lead a five-year pilot project in the region.
“I wasn’t hired because I was good,” Puska said, recalling what his boss told him many years later. “I was hired because I was young, and he knew it was going to take decades to figure out the problem.” Pekka Puska is the “Che Guevara” of public health initiatives.
With his grassroots organizing background, Puska and his team took an approach different from the traditional top-down government effort. Beginning in 1972, he worked with local health care systems and community organizations to disseminate a new message, and in the long run, they nudged the people of North Karelia into adopting a low-fat, high- vegetable diet. Among many other initiatives, Finnish scientists developed a type of rapeseed (canola) that would grow in Finland’s boreal climate and marketed its oil as a butter replacement. They showed housewives how they could make traditional meals with vegetables as well as meat.
The Impressive Results from the 5-Year North Karelia Project
By the end of the five-year project they were seeing impressive results:
- North Karelia reduced the heart attack death rate among middle-aged men by 25 percent.
- Lung cancer deaths in the same group fell by 10 percent, largely because of a dramatic reduction in smoking.
- Since then, the reduction in lung cancer mortality has been 20 percent.
- Mortality from all cancers dropped by 10 percent.
- The rest of Finland has followed the example of North Karelia and has also seen big improvements in these categories.
- Life expectancy of Finnish males in general has jumped by nearly ten years in these last three decades.
- As a result of his successes, Puska went on to become the head of the National Institute for Health and Welfare in Finland and president of the World Health Federation. I think of him as the Che Guevara of public health initiatives. The popular press refers to the North Karelia Project as “The Miracle Up North.” Many of the principles are part of the blueprint in our Blue Zones Project community makeovers.
What was it about Puska’s campaign in North Karelia that made it so effective? Could I learn anything from his team’s strategies to bring similar health benefits to American communities? These were the questions on my mind as I dug deeper into his story.
Dotted with 450 lakes and several hundred villages, North Karelia tucks into a crook of Finland’s border with Russia. Many of the taciturn, hard- working people who live there — descendants of reindeer herders — are farmers and lumberjacks, so quintessentially Finnish that they are often called the most Finnish of Finns.
The World’s Deadliest Diet
Before World War II, most North Karelians lived off the land, picking berries, hunting game, and fishing for perch, pike, smelt, and lake salmon. Besides the occasional bear mauling, their main health concerns were tuberculosis, infectious diseases, and death at childbirth. But after the war, hospital beds started filling up with victims of heart disease. Otherwise healthy men in their 30s and 40s were dropping dead from heart attacks. It wasn’t bad luck that was killing them — it was smoking and their diet.
During the war, when food was scarce, families in North Karelia had survived on rye bread, potatoes, and meat. That changed dramatically after the war, when veterans, as part of their compensation, were given small plots of land. Most of these veterans possessed little or no agricultural training, but it was easy enough for them to clear the land, buy a few pigs and dairy cows, and begin to support their families. That set the stage for what experts described as the world’s deadliest diet.
Take a half-starved population with a taste for fat and give them an abundance of pigs and dairy cows, and you’ve got a recipe for trouble. Butter soon made its way into almost every meal: butter-fried potatoes, buttered bread, tall glasses of full-cream milk at every meal, fried pork or meat stew for dinner, chased with buttered bread and milk. Vegetables were considered food for the animals. And dairy wasn’t just a source of calories, it was a source of regional pride. Yet it was taking a terrible toll.
Alarmed by this epidemic of heart disease, a Finnish professor named Martti Karvonen came to the United States in 1954 in search of possible solutions. One of the experts he consulted was Ancel Keys, a dietary researcher at the University of Minnesota in Minneapolis whom he’d met a few years before in Europe at a meeting of the Food and Agriculture Organization (FAO) of the United Nations. Keys had been promoting his hypothesis — controversial at the time and still attacked by some today — about the association between eating animal products and heart disease. Karvonen and Keys decided to join forces.
In what would become known as the Seven Countries Study, Karvonen, Keys, 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. Then, at five-year intervals, the study checked in on him again. A pattern soon emerged: The farther north the men lived, the more dietary fat they tended to consume (mostly from meat and dairy). 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.
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 ten 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 disease in the world. “The researchers would come here year after year, ask us questions, poke us with needles, and tell us we were the most unhealthy people in the world,” recalled Esa Timonen, the former governor of the region. “At a certain point we said, ‘Enough!’”
At the time, the causes of heart disease were still a mystery; doctors didn’t agree on what caused it, never mind how to cure it. So the first thing Puska did when he arrived in Joensuu, North Karelia’s capital, was to organize an idealistic young team to tackle the problem. They started by using essentially the same strategy that health officials had used to fight infectious diseases like tuberculosis or polio. They set up surveys to capture people’s health information. They identified the sick or the most-likely-to-get-sick, and then came up with prescriptions to help the highest-risk people stay healthier.
After that, the team gave out health information and set targets for the community to achieve in their efforts to lower heart disease. The problem, they soon realized, was that instead of a vaccination or an antibiotic to cure heart disease, the best medicine was avoiding many of the foods central to North Karelian culture. They printed up leaflets and posters, imploring people to consume less fat and salt and to eat more vegetables. But these Finns loved their bread, butter, and fried pork.
How could you break such habits?
“I could see the whole system needed to change,” Puska said. “The food industry, restaurants, cafeterias, and supermarkets — from the bottom up.” He started by consulting Geoffrey Rose, a British epidemiologist who believed 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 took this lesson to heart, realizing that the only way to cure North Karelia of heart disease was to change the local culture.
At afternoon “longevity parties,” a member of Puska’s team would give a talk about the connection between saturated fat and heart attacks. 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 about the connection between saturated fat and heart attacks. 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 farm wives how to cook plant-based meals that tasted good, Puska had found a way to disseminate the health message better than any leaflet could.
Lay Ambassadors, Food Producers, and Dairy Farmers
Puska, inspired by a former professor, Everett Rogers, who came up with the idea of “opinion leaders,” 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 fat consumption (and how to quit smoking), 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!”) Soon the message about replacing saturated fat with fruits and vegetables began to resonate with the people. They were starting to make a difference.
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 was interested in formulating healthier versions of their products. Why should they risk 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, waking up many people to the connection between dairy fat and heart disease.
The ads backfired, because they sparked a public debate, waking up many people to the connection between dairy fat 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 lingonberries 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.
After five years, Puska’s project was producing impressive numbers. North Karelians saw their average cholesterol numbers drop by 6 percent and their average blood pressure drop 4 percent for men and 7 percent for women. 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? His medical colleagues ridiculed the project, calling it “shotgun medicine.” But as it turns out, Puska’s strategy worked: He may have fired a shotgun, but he unleashed a healthy blast of silver buckshot that saved lives.
Not long ago, I visited North Karelia to see how this miracle had transformed people’s lives. Boarding a train in Helsinki, I 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: ‘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. If I was looking for a model for how to manufacture blue zones areas in America, I needed to absorb the principles of their work.
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 natural 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.
I was eager to meet some of the people Puska had tapped as ambassadors. I had heard that they tended to weigh less and have lower health care costs than non-volunteers of the same age. First I met 78-year-old Pentti Seutu, who confirmed that image. When I arrived at his home, Seutu was ripping through a pile of logs with a chain saw. Inside, his wife had prepared a dinner of vegetable casserole with lingonberry jam, a mushroom salad, fresh garden vegetables — cucumbers, lettuce, tomatoes — and two types of heavy rye breads. I asked Seutu why he’d volunteered for the project. “I like the feeling of giving back,” he said. “Besides, there’s not much else to do up here during the long months and the short days of winter.”
A delicious meal at a volunteer health ambassador’s home.
Outside of Joensuu, I met Mauno and Helka Lempinen in their snug cottage set in an apple orchard. Mauno, another wood cutter in his late 90s, was splitting wood when I arrived. The couple invited me inside, where we sat in a sunroom with warm birch floors covered by pastel carpets Helka had woven. The couple had come to North Karelia in 1973, when Mauno took a job as school principal. He soon adopted the local traditions and, like everybody else, started his day with buttered bread and coffee, lunched on cold cut sandwiches, and dined on pork stew. Vegetables were almost nonexistent as a part of their meals, he said. “People here thought of them as curiosities.”
In 1983 Mauno suffered a heart attack. The couple went into great detail describing to me how he panted “like he was giving birth” and the trauma it caused their three children who witnessed it. 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.
Puzzled, I asked about their normal diet today. “Well, for breakfast I had porridge with fruit. Lunch was vegetable soup with homemade rye bread,” Helka responded. “Dinner will be stew with potatoes and carrots and a little bit of meat, along with cucumber and lettuce salad.”
What then, I asked, prompted them to change the diet?
“We never changed our diet,” they insisted.
Wait a minute, I said, and flipped through my notes to read them the butter-and-pork pre-heart attack menu they’d described to me earlier. “Well, I guess we did change our diet,” Helka said after a long pause. When I asked why, they looked down and thought hard. They had no idea. “It just happened,” Mauno said finally. “But I guess it saved my life.” It occurred to me that herein lay the true miracle of North Karelia. An entire population, just like this couple, had changed their lifestyle without realizing it.
There it was, I thought: the key to Puska’s strategy. The North Karelia campaign had tackled the region’s health problem from so many different directions, its reforms were all but invisible. In Sardinia or Okinawa, centuries of cultural evolution had led to a lifestyle of long life, but here was a place that had manufactured a blue zones region and given its population a 10-year bump in longevity. And they had done so without massive health care spending.
They’d simply changed their environment.
Lessons Learned From North Karelia
Focus on the Ecology of Health
Pekka Puska’s team didn’t waste anybody’s time by lecturing them about individual responsibility. Instead, they put their resources into making long-lasting changes to the local environment.
Think Operating System, Not Program
The team developed a nimble, flexible approach that allowed them to innovate constantly.
Work with Local Health Systems
People listen to their doctors and nurses. The team recruited local health professionals to help disseminate the message.
Push, Push, Push
Working with “boots in the mud” was one of the North Karelia team’s mantras. They succeeded by relentless, congenial gnawing at the problem rather than heroic initiatives.
Find a Charismatic Leader
People like to identify a movement with individuals, and North Karelia found its leader in Puska.
The leadership and population of North Karelia was ready for a change. That made the work of the team easier, because they were responding to a plea from the community for help with heart disease.
Bottom Up, Top Down
The project team spent time and resources at the grassroots level to help people realize that their problem was diet. Then they harnessed that understanding to change food policy and the food system from the top down. The heavy lifting was done by the people themselves, making the connections between the two.
Measure, Measure, Measure
The team vigilantly measured the population’s lifestyle risk factors, including smoking and other health factors, at the beginning, middle, and end of the project to track progress and be able to prove the strategy worked.
Start Small, Go Big
Once North Karelia proved that this approach worked, Finland’s national health system instituted an effective countrywide preventive program, following a similar model.
Adapted from The Blue Zones Solution: Eating and Living Like the Healthiest People by Dan Buettner.