Gaining health : analysis of policy development in European ...

Chapter 4
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2.4.4. National demonstration projects – North Karelia, CINDI,
MONICA
In the 1970s, Finnish men had the highest CVD mortality in
the world. This was particularly serious in eastern parts of
the country, and especially in the province of North Karelia.
In response to a petition for help signed by a group of
provincial representatives, local and national authorities, in
collaboration with WHO, launched a comprehensive effort
in 1972 to tackle CVD morbidity and mortality.
The main medium-term objectives were to reduce smoking
prevalence and lower cholesterol and blood pressure levels
in the whole population, but particularly among middleaged
men. The existing health and social services, together
with government and private authorities, were all expected
to play an active role at local and national levels.
The Project included a comprehensive package of actions
affecting various settings and sectors: legislation on tobacco
control and the production of certain foods (such as mixing
oil and butter); regulations concerning smoke-free areas
and healthier school lunches; collaboration with manufacturers
and retailers on the production and sale of healthier
food products (less salt and fat); promotion of berry
farming; broad use of the mass media to raise awareness;
involvement of community organizations (local politicians
and opinion leaders, the Heart Health Association, women’s
organizations and sports clubs) with special attention to
providing healthier meals at the workplace; and far-reaching
educational efforts through schools and other educational
institutions.
The changes in health behaviour and their biological consequences
were quite remarkable, with changes in diet playing
a particularly important role (36). The risk factor changes
were followed by a clear fall in mortality from coronary
heart disease (37). In the initial pilot project period
1972–1977 only North Karelia was targeted, but given the
interest of the mass media, many of the Project’s messages
quickly spread throughout the country. After the first ten
years, the scope of the project was enlarged to cover other
lifestyle-related chronic diseases and to promote general
health. Over a 30-year period, the age-standardized mortality
rate from coronary heart disease for men aged 35–65
years fell by 82% in North Karelia and, partly as a result
of the demonstration effect of the project, by 75% in the
whole country, with a similar decrease for women.
The Project continues to serve as a national demonstration
project, and local agencies organize not only regional but
also national campaigns such as the National Quit & Win
campaign in 2005, and developmental work to create local
health promotion strategies in municipalities. The surveys
initially designed to evaluate the North Karelia project
gradually developed into a national risk factor monitoring
system (FINRISK studies).
Among the interesting characteristics of the North Karelia
Project are its systematically developed evidence base; solid
partnerships between national and local government, civil
society and the private sector; the interaction of health
services with other community activities; and the positive
media interest. Within these partnerships, there has been a
clear sense of government responsibility for health promotion,
with civil society playing both a supporting but also
a watchdog role and, over the years, the private sector
gaining better understanding of a health promoting business
being a more sustainable business.
Towards the end of the 1970s, intense interest in population
trends in CVD encouraged WHO to bring together investigators
from a number of countries to standardize their
definitions and measurements and combine their findings
(6). This led to the WHO MONICA Project. Finland not
only became a member of this project, monitoring CVD in
three regions (North Karelia, Kuopio Province and Turku/
Loimaa), but hosted the MONICA data centre at KTL in
Helsinki.
Case studies: policy development in countries for tackling noncommunicable diseases