Finland’s North Karelia Project: Structural Barriers to Changing a Food Economy

The North Karelia region of Finland, located along the eastern border with Russia, experienced severe economic and political instability throughout the 20th century. Much of this upheaval stemmed from Soviet annexation of large portions of the area in the 1940s, which resulted in the forced relocation of more than 400 000 Finns and the loss of culturally important lands and waterways. Small-scale farming, particularly animal husbandry, became increasingly important to the North Karelian economy as the population increased as a result of relocation. As the number of dairy and pig farms grew, so too did the region’s incidence of coronary heart disease (CHD). By the 1960s, North Karelia suffered the highest rates of CHD mortality in Finland, and the country itself suffered from some of the highest rates in the world.

Evidence of the area’s reliance on farming was readily apparent to me when I lived in Joensuu, the capital of North Karelia, as an undergraduate studying Finnish history in 2008. I was reminded once again of the importance of dairy farming when, as a medical history PhD student, I received a Fulbright grant in 2014 to study medical, governmental, and agricultural responses to the heart disease crisis in Finland. I will never forget the spread of food at the opening reception for Fulbright grantees in Helsinki—there was more butter and cheese than I ever thought possible! Not wanting to appear rude, I slathered generous amounts of butter onto the warm, fresh rye bread. As I ate, I wondered what this same reception may have looked like in 1970. Would there have been even more high-fat foods? What would it have looked like in 1980, almost a decade after the start of the North Karelia Project (NKP), the CHD community intervention program that is the subject of Mikko Jauho’s article (p. 890)?

PRIORITIZING BEHAVIORAL CHANGE

Jauho provides a thorough but succinct overview of the “pilot phase” of NKP. He explains that the project prioritized behavioral change as the way to reduce risk factors for (and thus incidence of) CHD, whereas larger structural changes were excluded from NKP’s initial purview. Because medical and lay communities in Finland believed that CHD was a health emergency that required immediate action, it is unsurprising that NKP focused its initial efforts on behavior modification. But why, exactly, were structural changes excluded? Was urgency a factor? Was there a lack of government support for instituting complex changes? Were insufficient funds a reason? Did investigators fail to grasp the importance and influence of socioeconomic factors on CHD?

Jauho’s final paragraph alludes to the latter: the project’s foregrounding of individual lifestyle choices eclipsed the larger scale of change necessary to lower CHD mortality rates. Arguably, NKP was hampered by its failure to address social determinants of health. Because dairy farming was an important part of the North Karelian economy and culture, fatty foods were abundant and cheap. Individuals struggled to understand why they should buy specialty items from a store when they could get milk from their own or a neighbor’s farm. Beyond this, many individuals simply were not in a position to buy what they could get for free.

REDUCING RISK THROUGH STRUCTURAL CHANGE

My forthcoming dissertation, “Capitalizing on Crisis: Dietary Fat, Scientific Uncertainty, and Coronary Heart Disease as a National Health Emergency, 1945–1995,” compares shifting understandings of, and responses to, heart disease in the United States and Finland. In my dissertation, I look to some of the NKP’s efforts to address structural barriers to health in its later years. The 1986 East Finland Berry and Vegetable Project, for example, was a multipronged approach that sought to increase fruit and vegetable consumption across the nation, with a specific focus on Finnish-grown foods.¹ In this effort, it sought to increase domestic production by transitioning farmers in North Karelia from dairy products to berries, which would (ideally) result in a more stable product market and, thus, a more reliable and steady income for the farmers. Had NKP instituted this arm of the project in the 1970s, farmers and residents of the region may have felt more empowered to make dietary changes. It could have removed initial monetary barriers to entry while alleviating concerns that people’s food choices would hurt their (or their neighbor’s) livelihood. In addition to reducing dietary risk, this structural change could have mitigated the manifold health risks that stem from economic insecurity. Seen from this angle, bigger picture structural interventions held the power not only to lower incidence of CHD but also improve people’s lives as a whole.