The cornerstone of unity

55 THE NORTH KARELIA PROJECT
Living standards in Finland began to rise rapidly after World War II, and infectious diseases were not having 
such a big impact on health. In their place had come chronic national diseases, especially heart and vascular 
disease and cancer. In the 1970s Finland had the highest rate of heart disease in the world. In particular the 
death of working men due to heart disease was a blow to the health of the nation. 
Concerns about the exceptionally high rate of coronary heart disease (CHD) in the Province of North Karelia 
resulted in a petition being signed in Joensuu in January 1971. Representatives of various groups from the 
province, led by the governor, appealed to the state authorities for urgent and effective help to improve the 
alarming situation. And so began the preparatory work which resulted in the launch of the North Karelia Project. 
When the project began, cardiovascular disease was already the number one cause of death in the 
industrialised world, but in the early 1970s much less was known about its causes and the focus had been on 
treatment and rehabilitation. However, some studies had pointed to some likely causal risk factors, and new 
information provided new ways to help prevent it. It was observed that there was no reason to blame bacteria or 
viruses, as with pestilence, but rather that certain lifestyles increased the risk, and it was thus perceived that only 
preventative measures could bring about any real change in the nation’s health. In this way the North Karelia 
Project set about reducing the nation’s risk factors. 
The available data showed that the identified risk factors were common among the Finnish and especially the 
Northern Karelian male popu
lation. The population’s high serum cholesterol levels could be explained by their 
diet, which was abundant in saturated fats and salt. It included few vegetables but there was plenty of butter, fat 
and full-cream milk. It was very common for men to smoke tobacco. 
The project’s main focus was to change the behaviour of the population (especially smoking and dietary 
habits), and these starting points created a strategy of communitybased prevention work. The goal was to 
broadly influence the entire community, not just patients in care or those at high risk. In the 1970s this was quite 
a groundbreaking approach. 
Work began with the stated aim of changing the nation’s living habits (especially with regards to diet and 
smoking), but this met with strong opposition in the mainly agrarian community. As the project had a community-
based strategy, it did not include centralised intervention, but the work was done through local community 
organisations and by local people themselves. The project provided the means, trained and motivated the 
people, and coordinated, monitored and evaluated the activities. 
The five year project started with a comprehensive baseline study in spring 1972 and ended with a new 
population survey in spring1977, and the experiences gained there have since been implemented nationally. 
Preventive measures and monitoring continued in North Karelia until 1997. Over the 25-year period the project 
achieved all its objectives, and undoubtedly much more. 
The published results of the project show how major changes took place with regards to the target risk factors. 
Male smoking was greatly reduced and dietary habits changed markedly. The changes to the quantity and 
quality of fat in the diet were especially significant: in 1972 over 80% of the population reported that they mainly 
used butter on bread, but in 1997 the proportion was less than 10%. Dietary changes have led to about a 17% 
reduction in the mean serum cholesterol level of the population, and elevated blood pressure has been brought 
well under control. 
Reduced levels of risk factors also led to a rapid decline in mortality rates from coronary diseases. In the 
1970s, mortality from CHD among working-age men fell rapidly in North Karelia. National action subsequently 

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led to changes that affected the whole country. The experiences learned from the North Karelia Project have 
been utilized diversely in e.g. wide-ranging television shows and national projects. It has also shown how 
modern national diseases could be challenged through lifestyle changes. 
The organisation that was created to evaluate the North Karelia Project has been developed into the Finnish 
National Institute for Health and Welfare which carries on mo
nitoring the nation’s health. It has demonstrated 
how the level of risk factors among the Finnish population have fallen very significantly as a result of a drop in 
smoking and dietary changes. Death from heart disease among working-age men is now 80% lower than when 
the project began, and death from heart disease has also reduced. Death among working-age men in general 
has reduced by half and the subjective health of the nation has improved. Finns now enjoy an extra ten years of 
life expectancy, and they are generally healthy years. 
The North Karelia Project has thus become the leading example of how the prevention of heart and vascular 
disease is possible and worthwhile. While heart diseases and chronic diseases in general have become an 
important health problem in this day and age, and also the most likely cause of death in the developing countries 
too (the cause of death in over 60% of all deaths wordwide), the North Karelia Project and Finland’s experience 
are deeply significant. International interest in the results and experiences of the project is very wide. These 
experiences have been useful in scientific cooperation between different countries and international 
organisations, especially programmes organised by the WHO. 
A top-level UN meeting on the prevention of chronic non-communicable diseases was held in New York in 
2011. It was clear that this is not just a national health problem but, especially in developing countries, a future 
hindrance to social and economic development. The recommendations of the meeting correspond to and also 
reflect the North Karelia Project and Finland’s experiences of it. It is possible to prevent these diseases and 
essentially improve the health of the nation through influencing people’s way of life, which is the most cost-
effective way and a guarantee of future development. 
Pekka Puska 
– Emeritus Director General,
National Public Health Institute