13
Chronic Disease Prevention in the New Independent States: Finnish Experiences

Pekka Puska

Introduction

In the early 1970s, Finland was faced with a massive epidemic of atherosclerotic cardiovascular diseases. A range of research-based activities was undertaken to tackle the problem, including a major national preventive demonstration program known as the North Karelia Project. In 20 years, this work has been associated with a marked reduction in target risk factors and with a more than 50 percent reduction in cardiovascular disease mortality rates among the middle-aged population.

As documented in several of the early chapters of this volume, the republics of the former Soviet Union are now facing a similar serious problem of chronic disease, which represents a major challenge to the public health in these states. During the last few years, several collaborative activities between Finland and its neighbors Estonia and the Republic of Karelia (now part of the Russian Federation) have been initiated to increase understanding of the problem and help launch effective preventive programs.

This chapter first describes the Finnish experience with the North Karelia Project. It then presents results and experiences from the collaboration with Estonia and the Republic of Karelia. Results are drawn from epidemiological comparisons and health behavior assessments, based on strictly comparable surveys. Recent and planned collaborative intervention activities are also described. Finally, health challenges and the potential for taking practical action toward chronic disease prevention in the New Independent States (NIS) are discussed.



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--> 13 Chronic Disease Prevention in the New Independent States: Finnish Experiences Pekka Puska Introduction In the early 1970s, Finland was faced with a massive epidemic of atherosclerotic cardiovascular diseases. A range of research-based activities was undertaken to tackle the problem, including a major national preventive demonstration program known as the North Karelia Project. In 20 years, this work has been associated with a marked reduction in target risk factors and with a more than 50 percent reduction in cardiovascular disease mortality rates among the middle-aged population. As documented in several of the early chapters of this volume, the republics of the former Soviet Union are now facing a similar serious problem of chronic disease, which represents a major challenge to the public health in these states. During the last few years, several collaborative activities between Finland and its neighbors Estonia and the Republic of Karelia (now part of the Russian Federation) have been initiated to increase understanding of the problem and help launch effective preventive programs. This chapter first describes the Finnish experience with the North Karelia Project. It then presents results and experiences from the collaboration with Estonia and the Republic of Karelia. Results are drawn from epidemiological comparisons and health behavior assessments, based on strictly comparable surveys. Recent and planned collaborative intervention activities are also described. Finally, health challenges and the potential for taking practical action toward chronic disease prevention in the New Independent States (NIS) are discussed.

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--> The North Karelia Project This section provides an overview of the project and describes its evaluation and national applications, the main results of evaluation studies, and conclusions that can be drawn from the project. Project Overview In the decades after World War II, Finland faced serious noncommunicable disease epidemics resulting from increased occurrence of the major chronic diseases—an increase that took place in spite of growth in health services and in the general level of income. In the early 1970s, Finnish men had the highest mortality rate from coronary heart disease in the world (Pisa and Uemura, 1988). The mortality rate from cancer and the rate for all causes of death were also high. Finland undertook several measures to control these new epidemics and to improve the health of the nation. One major action taken was the start of the North Karelia Project. Faced with the great burden of heart disease and other major chronic diseases, representatives of the population in the province of North Karelia in eastern Finland signed an urgent petition to the Finnish government to start a program aimed at reducing the high mortality from these diseases. In response, Finnish experts, local representatives, and World Health Organization (WHO) representatives designed and formulated a national demonstration project to explore avenues for the prevention of premature mortality, especially from cardiovascular diseases. Under this initiative, North Karelia, which is neighbor to the Russian Republic of Karelia, has been a demonstration area for a comprehensive community-based preventive program since 1972. The major objective of the North Karelia Project has been to decrease mortality and morbidity rates from cardiovascular and other chronic diseases, as well as to promote general health among the population of the area. Special emphasis has been on the middle-aged male population, which had especially high mortality rates prior to the start of the project. The basic idea of the project was to reduce levels of well-established lifestyle-related risk factors among the population through a well-conceived and comprehensive community-based intervention. Previous research, such as the Framingham Study (Wilson, 1994; Brand et al., 1992; Kreger, 1991) and the Seven Countries Study (Keys, 1980), had clearly identified the important and likely causal role of a few risk factors, notably smoking, elevated serum cholesterol (related to diet), and elevated blood pressure, and a review of available knowledge on risk factors for heart disease among the Finnish population showed these three to be most important. The latter two factors were probably associated with the local diet, which was very high in saturated fats. Thus the desired major

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--> reductions in risk factor levels would call for changes in health-related lifestyles and their determinants within the community. The international medical and epidemiological literature and local prevalence rates were used to choose the right targets for prevention. But since prevention in practice requires changing lifestyles, relevant behavioral and social theories were also applied. North Karelia has served as a demonstration area for all of Finland to determine how and to what extent available medical knowledge can be used for effective chronic disease prevention in a real-life situation. Carefully conducted evaluative research has documented the experiences and results of the program, which in turn have been used to guide national activities (Puska et al., 1981; Puska et al., 1985). Much of the practical preventive health work in North Karelia has been integrated into the existing service structure and local organizations. The role of the project has been to define the objectives of the work, to train, to coordinate, and to promote the project activities, as well as to assess the results. Most of the actual work has been done by the community itself; thus, community involvement and people's participation have been emphasized. The project's health education work has included teaching practical skills needed to make the change to a healthier lifestyle. Social support for such changes has been provided in many ways. Environmental changes (such as smoking restrictions and collaboration with the food industry) have been promoted as part of the comprehensive community effort for healthy change. Evaluation And National Applications In the spring of 1972, prior to the start of the project, a large baseline survey was carried out in North Karelia and in the chosen matched reference area, Kuopio province. Target risk factors, related behaviors, and background variables among the population were carefully measured. Because of the initial fruitful experience with the project and associated national needs, the project became actively involved in national risk factor reduction activities after its initial 5-year period (1972-1977), serving as a major national demonstration program. After 10 years, the project scope was enlarged to include more integrated prevention of major noncommunicable diseases and promotion of health. This expansion took place in association with the respective WHO programs: CINDI (Countrywide Integrated Noncommunicable Disease Intervention—WHO/ EURO) and INTERHEALTH (Integrated Noncommunicable Disease Prevention—WHO/HQ). At the same time, major activities were launched for the prevention of risk factors among youth. Assessment of changes in target risk factors and risk-related lifestyles during the course of the project has been based on repeated large population surveys in North Karelia and the initial reference area at 5-year intervals (1977, 1982, 1987,

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--> and 1992). Since 1982, the surveys have also been carried out in an area in South West Finland to help assess national changes. Smaller annual surveys have been carried out to assess health behavior changes and the change process. Disease rates in North Karelia and elsewhere have been monitored by special disease registers and by mortality data. Main Results Of Evaluation Studies This section provides a brief summary of results of evaluation studies of the project. These results are for people aged 30-59, examined in independent population surveys using carefully standardized methods. The methods and materials of the surveys have been described in detail elsewhere (e.g., Vartiainen et al., 1994). The mortality data cited here are based on analyses of official mortality statistics and are also presented elsewhere (e.g., Puska et al., 1994). The mortality statistics have been validated by the acute myocardial infarction registries, operating according to WHO MONICA (Monitoring Cardiovascular Disease Study) diagnostic criteria (Palomäki et al., 1994). Table 13-1 shows that among the male population in North Karelia, smoking greatly decreased over the 20-year period, and dietary habits changed markedly. In 1972, about 52 percent of middle-aged men in North Karelia smoked; in 1992, the percentage had fallen to 32 percent. In the early 1970s, consumption of fresh vegetables and vegetable oil products was very rare; now it is much more widespread. In 1972, about 90 percent of the population of North Karelia reported using mainly butter on bread; in 1992 the figure was less than 20 percent. Dietary changes over the 20-year period led to about a 15 percent reduction in the mean serum cholesterol level of the population. Elevated blood pressures were brought well under control, and leisure-time physical activity increased. The above changes in risk factor levels in North Karelia were significantly greater than the corresponding changes in the original reference area throughout the 1970s. Thereafter, the changes were rather parallel throughout all Finland. During the last few years, new and remarkable changes have taken place, particularly cholesterol-lowering dietary changes that have been associated with major further reductions in serum cholesterol levels. Table 13-2 shows that over the 20-year period, the annual mortality rate from coronary heart disease among the middle-aged (below age 65) male population in North Karelia was reduced by about 50 percent. In the 1970s, this reduction was especially rapid in North Karelia; in the 1980s, the favorable changes took place across all Finland (see Figure 13-1). The mortality rate from coronary heart disease in 1992 was 59 percent lower than the preprogram level (mean of the period 1969-1971). At the same time, as shown in Figure 13-2, cancer mortality also declined, more than 40 percent in North Karelia and over 30 percent across all Finland. With greatly reduced cardiovascular and cancer mortality, the all-

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--> TABLE 13-1 Changes in the Main Risk Factors in North Karelia (NK), Kuopio Province (KUO), and the South-West Finland Area (SW): Population Aged 30-59   Smokers (%) Serum Cholesterol mmol/l Systolic Blood mmHg Pressure   NK KUO SW NK KUO SW NK KUO SW Men 1972 52 50   6.9 6.7   149 146   1982 36 42 39 6.3 6.3 6.1 145 147 144 1992 32 37 39 5.9 5.9 5.8 142 140 139 Women 1972 10 11   6.8 6.7   153 147   1982 15 15 22 6.1 6.0 5.9 141 143 136 1992 17 19 23 5.6 5.5 5.5 135 136 134 NOTE: mmol/l = millimoles per litre; mmHg = millimeters of mercury. SOURCE: Cross-sectional surveys of 1972, 1982, and 1992.

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--> TABLE 13-2 Change in Mortality in North Karelia in 20 Years: Men Aged 35-64 (age-adjusted, calculated from regression line of 1969-1990) Mortality Mortality rate per 100,000, 1970 20-Year Change (%) All causes 1,556 -37 Cardiovascular disease 912 -46 Coronary heart disease 695 -46 All cancers 293 -45 Lung cancer 167 -63 cause mortality rate declined by about 40 percent, leading also to greater life expectancy (Table 13-2). Associated with the favorable risk factor and lifestyle changes, the general health status of the population greatly improved. Discussion And Conclusions From The North Karelia Project Throughout its 20-year period, the project has made substantial progress in improving the health of the population. This progress was made even though—at least in the early years—the health service resources in North Karelia were scarce. North Karelia has been the province with the lowest socioeconomic level in Finland, and in the 1970s in particular, it was characterized by many social problems, such as unemployment. Also, community norms were rather traditional, tending toward resistance to lifestyle innovations. Moreover, there was a great deal of dairy farming in the area, resulting in the production of large amounts of dairy fat. Local health services and health personnel in North Karelia have cooperated well with the project and have thus formed a firm backbone for the prevention activities. Numerous community organizations have contributed over the years in various ways. Because the project activities have been integrated into the existing health services and broad community participation has been a key feature, the overall costs of the program have been modest. The experiences and results of the project support the idea that a well-planned and -designed community-based program can have a major impact on lifestyles and risk factors, and that this impact in turn will lead quite rapidly to reduced cardiovascular disease rates in the community. Furthermore, the project has demonstrated the strength of the community-based approach in changing risk

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--> Figure 13-1 Annual mortality rate from coronary heart disease, males aged 35-64, per 100,000. Figure 13-2 Annual mortality rate from cancer, males aged 35-64, per 100,000. factor behaviors. Much practical experience has been gained in organizing such activities. The project has also shown that a major national demonstration project can be a strong tool for favorable national development. The decline in heart disease mortality during the last few years in Finland has been among the most rapid in the world. Active international collaboration with WHO and other agencies initially helped the project. Thereafter, WHO assisted in applying the project approach and experiences elsewhere. During the last few years, several community-based projects and national demonstration programs have been launched in many countries of the world, including countries of Eastern and Central Europe. Such

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--> efforts will ultimately help control these modern chronic disease epidemics around the world and tell us more about the usefulness of various intervention approaches in different cultural settings. Collaboration with Estonia and the Republic of Karelia of Russia In years past, Finland has had many active contacts with neighboring republics in the former Soviet Union, including contacts in public health and health research. However, contact with its closest neighbors, the Republic of Karelia in the east and Estonia in the south, was relatively scarce until recently. Contacts between Finland and the Baltic states have since grown rapidly. Especially close and active are the contacts between Finland and Estonia. The distance between the two capitals, Helsinki and Tallinn, is only 60 kilometers, and the Finnish and Estonian languages are closely related. Contacts between Finland and the Republic of Karelia have also increased greatly. At the same time that experiences with chronic disease prevention have been very encouraging in Finland, the neighboring countries of Estonia and the Republic of Karelia, as well as other NIS countries, have been facing major health problems, especially those involving noncommunicable diseases. Available information, such as that from Russia, shows high mortality rates and unfavorable trends for these diseases (Demin, 1993; see also the chapters by Shkolnikov et al., Vassin and Costello, Kingkade and Arriaga, and Murray and Bobadilla in this volume). Present economic and political problems obviously hinder the initiation of long-term systematic action to improve the health situation in Estonia and Russian Karelia. However, health authorities and researchers have become very aware of the need for action, partly through contacts with Finnish researchers and health authorities and exposure to the North Karelia Project. Especially in Russian Karelia, but also in Estonia, the need for a similar project has been noted. Numerous contacts among researchers and authorities from Finland and its two neighbors have highlighted the need for good data and information systems, for good training opportunities, and for exchange of experiences. At the same time it is realized that each country must develop its own program content to suit the local situation. In this collaboration, comparable data have been collected, with the aim of establishing health monitoring systems that will enable sound comparisons in the future. To the extent possible, international and especially WHO-initiated methods (MONICA, CINDI) have been used, as well as some more detailed methods and procedures developed in Finland (World Health Organization, 1989; Puska, 1993b). This section first describes various health databases that have been developed and used within the collaboration. It then presents some findings from the

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--> collaboration concerning the health situation in Finland, Estonia, and the Republic of Karelia, with particular emphasis on chronic disease prevention and health promotion. Finally, it describes plans for collaborative intervention. Health Databases Databases developed and used as part of the collaboration include mortality statistics; cardiovascular disease incidence rates; population risk factor levels; and health behavior, health-related behavior, and subjective health (an individual's perception of his or her health status). Mortality statistics following WHO guidelines are available for Finland and Estonia. For the Republic of Karelia, the mortality statistics were specially collected from the statistical center in Petrozavodsk. For information on cardiovascular disease incidence rates, WHO MONICA-affiliated disease registers have long operated in Finland. In collaboration with the Finnish team, Estonian researchers have established a myocardial infarction register in Tallinn (Laks et al., 1991). For the Republic of Karelia, very little comparable information on disease incidence rates is available. For population risk factor levels, well-standardized, repeated population surveys have been carried out in Finland at 5-year intervals. The latest took place in 1992 in four areas of the country (North Karelia, Kuopio province, South West, and Helsinki region). In connection with this survey, the Finnish team, assisted by local personnel, also carried out a survey in Pitkäranta, a district in the Republic of Karelia (Puska et al., 1994). In this survey, the numbers (and participation rates) for men and women surveyed, respectively, were 673 (68 percent) and 805 (81 percent) in North Karelia, and 379 (77 percent) and 458 (92 percent) in Pitkäranta. Somewhat comparable information was collected in Tallinn within the CINDI project (Voloz et al., 1990). In areas such as health behavior, health-related behaviors, and subjective health, an annual monitoring system using surveys of cross-sectional national population samples, distributed by mail, has been in operation in Finland since 1978 (Puska, 1996). In 1990, in connection with a major joint smoking-cessation program on television in Finland and Estonia, a national survey on health behavior, strictly comparable to the Finnish surveys, was carried out in Estonia (Korhonen et al., 1993). A new survey for a new sample was carried out there in 1992 (Lipand et al., 1993). Thus Estonia has developed a health behavior monitoring system comparable to that of Finland, operated in close collaboration with the Finnish National Public Health Institute. The numbers surveyed (and participation rates) in 1992 were, for men and women, respectively, 1,733 (69 percent) and 1,981 (80 percent) in Finland, and 451 (60 percent) and 497 (66 percent) in Estonia. The other Baltic states have since planned to participate in this joint effort, recently named FINBALT HEALTH MONITOR. The 1992 survey in Pitkäranta included most of the common health behavior questions contained in

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--> the Finnish and Estonian surveys, and the aim is to continue this monitoring in Pitkäranta. Health Situation Mortality and Disease Patterns Figures 13-3a and 13-3b show recent (1992) age-adjusted mortality rates in Finland, Estonia, and the Republic of Karelia. They also show the rates in the province of North Karelia for the period 1990-1992 and 20 years earlier, before the project. The age-adjusted all-cause mortality among the population aged 35-64 in the Republic of Karelia is about double that in Finland. The situation in Estonia is much like that in the Republic of Karelia. The greatest killer among all three populations is cardiovascular disease. However, the primary cause of excess mortality in Estonia and the Republic of Karelia, though not in Finland, is cancer and ''other" causes (a high proportion of which consists of violent deaths). In all populations, the mortality rate among women is much lower than that among men, but there is little difference among the three within the sexes. Figures 13-3a and 13-3b also show how much the situation in North Karelia before the project resembled the recent situations in the Republic of Karelia and Estonia, although cardiovascular mortality was remarkably high in North Karelia at that earlier time. Figure 13-3a Age-adjusted mortality rates in Republic of Karelia, Estonia, and Finland, 1991, males aged 35-64.

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--> Figure 13-3b Age-adjusted mortality rates in Republic of Karelia, Estonia, and Finland, 1991, females aged 35-64. In Finland, the MONICA-based acute myocardial infarction registers have corroborated the mortality statistics shown in Figures 13-3 a and b, concerning both international comparisons and declining trends (Mustaniemi, 1993). Preliminary experience from the acute myocardial infarction register in Tallinn has corroborated the high cardiovascular disease rates there (Laks et al., 1991). General Health The prevalence of certain symptoms, such as backache, headache, varicose veins, insomnia, and depression, was measured in the comparable surveys in Finland and Estonia. The results indicate consistently that various general symptoms are more common in Estonia than in Finland; they seem to be more common in Pitkäranta as well. Table 13-3 shows results for subjective health, as measured by similar self-administered questionnaires in two different surveys. Results are given for all Finland and Estonia from health behavior surveys (sample population aged 15-64) and for the province of North Karelia and Pitkäranta district in the Republic of Karelia from risk factor surveys (sample population aged 25-64). "Good" or "fairly good" subjective health was reported much more commonly in Finland than in Estonia and the Republic of Karelia (Pitkäranta district).

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--> TABLE 13-3 Subjective Health in Finland and Estonia (population aged 15-64) and in the Province of North Karelia (Finland) and Pitkäranta (Republic of Karelia) (population aged 25-64)   Men Women Subjective Health Finland Estonia North Karelia Pitkäranta Finland Estonia North Karelia Pitkäranta Good or Fairly Good 68 38 50 34 69 29 58 23 Average 25 56 38 58 24 62 36 65 Rather poor or poor 7 6 12 8 7 9 6 12   SOURCES: For Finland and Estonia, Health Behavior Surveys: for North Karelia and Pitkäranta, Risk Factor Surveys. All surveys from spring 1992.

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--> Risk Factors Table 13-4 shows strictly comparable information on the occurrence of chronic disease risk factors in North Karelia and the Pitkäranta district, as measured in the same joint risk factor survey. In North Karelia, total serum cholesterol is somewhat higher than in Pitkäranta among both sexes. In Pitkäranta, the women are more obese, have higher blood pressure, and smoke less than women in North Karelia. On the other hand, men in Pitkäranta are less obese, have lower triglycerides, but smoke much more than men in North Karelia. Similar information, but not exactly comparable, from the CINDI survey in Tallinn (Estonia) indicates that the cholesterol levels there are at least as high as in Finland, while blood pressure may be a little lower. The obesity pattern in Tallinn seems to resemble that of Pitkäranta more than that of Finland. TABLE 13-4 Mean Levels of Risk Factors in North Karelia (Finland) and Pitkäranta (Republic of Karelia), Population Aged 25-64, 1992   Men Women   North Karelia Pitkäranta North Karelia Pitkäranta Serum Cholesterol (mmol/l) 5.8 5.2 5.6 5.3 HDL-cholesterol (mmol/l) 1.3 1.4 1.5 1.4 Triglycerides (mmol/l) 1.9 1.2 1.4 1.2 Syst. blood pressure (mmHg) 140 142 132 144 Diast. blood pressure (mmHg) 83 83 78 82 BMI (kg/m2) 27.0 25.2 26.5 28.0 Smoking (%) 31 65 16 11 NOTE: mmol/l =millimoles per litre; mmHg = millimeters of mercury: kg/m2 = kilogram/square meter. SOURCE: Joint risk factor survey of 1992.

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--> Health Behavior Figures 13-4a and 13-4b show more detailed information on age- and sex-specific smoking rates in Finland, Estonia, and the Republic of Karelia. The data for Finland and Estonia are derived from the health behavior surveys and the data for the Republic of Karelia (Pitkäranta) from the risk factor survey there. The questions used in all the surveys were the same. Among men, smoking is clearly least common in Finland and most common in Pitkäranta. Very alarming is that in Pitkäranta, 77 percent of the men in the youngest age group (25-34) smoke. For women, the differences in smoking among the three populations are much less pronounced. Overall, the smoking rate among women is lowest in Pitkäranta. However, in Pitkäranta and Estonia, the age gradient is steep, and the youngest women (aged 25-34) clearly smoke most; in Estonia, more than 30 percent of the women in this age group smoke. In Finland, Estonia, and the Republic of Karelia, the above-mentioned surveys included similar questions about the type of fat used on bread and the use of fresh vegetables. As noted earlier, butter is seldom used on bread in Finland, by 17 and 13 percent of males and females, respectively, while butter is by far the predominant choice in Estonia and the Republic of Karelia, where over 90 and 70 percent of the populations use it, respectively. These data, of course, say nothing about quantities used or availability. Daily consumption of fresh vegetables is much more common in Finland Figure 13-4a Age-specific smoking rates in Finland and Estonia (health behavior surveys) and Republic of Karelia, Pitkäranta (risk factor survey), males.

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--> Figure 13-4b Age-specific smoking rates in Finland and Estonia (health behavior surveys) and Republic of Karelia, Pitkäranta (risk factor survey), females. than in Estonia or the Republic of Karelia (Pitkäranta). In Finland, one-quarter to one-third of the population consume fresh vegetables. Consumption of fresh vegetables is very limited in Estonia, at less than 10 percent, and in the Republic of Karelia, at less than 3 percent. Comparable data on leisure-time physical activity reveal it to be quite common in Finland and Estonia, where roughly 50 percent exercise, but surprisingly rare in the Republic of Karelia (Pitkäranta), where fewer than 20 percent exercise. Recent And Planned Collaborative Interventions Collaboration among Finland, Estonia, and the Republic of Karelia has concerned not only the establishment of the previously mentioned health databases, but also intervention plans. Estonia is actively planning effective programs for disease prevention and health promotion, although the effort faces many constraints in the present situation. The Finnish-Estonian cooperation has been supported in large part by the establishment of the National Health Education Center in Estonia and the launching of its health education activities. Also, the collaboration has focused on the WHO-initiated CINDI program as a comprehensive and effective tool for chronic disease prevention in Estonia. In addition, a broad range of other collaborative activities has taken place between Finland and Estonia in formulating and implementing strategies for disease prevention and health promotion.

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--> In the Republic of Karelia, the challenges are, if possible, even greater than those in Estonia. The republic is geographically rather isolated, there are severe economic constraints, and the unstable political situation adds to the magnitude of the problems. Nevertheless, the Ministry of Public Health is determined to plan and launch preventive health policies and activities. In collaboration with Finnish experts and authorities, several joint seminars and meetings have taken place. Plans are to establish a special center for preventive activities in the Karelian capital, Petrozavodsk. In the Finnish-Karelian collaboration, the district of Pitkäranta has been chosen as a special demonstration area for preventive activities. Since a large population survey was conducted in 1992 to assess the baseline situation, several preventive activities have been collaboratively planned and initiated in Pitkäranta. The project in Pitkäranta is also planned to serve as one of the demonstration areas of the CINDI project in the Russian Federation (coordinated by the Institute of Preventive Medicine in Moscow). Health Challenges and the Potential for Chronic Disease Prevention The Importance of Lifestyle Changes It is obvious that major improvements in public health in Estonia and the Republic of Karelia, as well as in many other parts of Russia and other NIS countries, are overwhelmingly dependent on changes in the rates of the major noncommunicable diseases. Those rates, in turn, are greatly dependent on future developments in the lifestyles associated with these diseases. These lifestyles influence not only the rates of the major diseases, but also the general state of health of the population. Several factors could hamper future positive developments. Obviously, the present economic and political problems make positive action all the more difficult. In addition, in the new social climate, people associate fashionable Western lifestyles with unhealthy patterns such as cigarette smoking, heavy meals, and sedentary activities. These images are often supported by heavy Western commercial pressure, such as from the Western tobacco industry (see Pierce, in this volume) and the Western dairy industry. On the other hand, several factors favor positive developments. Health authorities and experts in the region clearly see the need and potential for a modern health promotion strategy. Preventive health and adoption of healthy lifestyles are affordable means of achieving great health improvements, for both the individual and the nation, in a situation where possibilities for expensive clinical cures are greatly limited. A country's public health situation can be viewed as a transition. Traditional poor societies usually have (in spite of other problems) low chronic disease rates

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--> because of their relatively simple and more natural lifestyles (see the chapters by Kingkade and Arriaga and by Murray and Bobadilla in this volume). With relative increases in economic levels, unhealthy lifestyles often emerge, and the chronic disease burden greatly increases. However, in most modern societies, with public emphasis on quality of life and health, people shift lifestyles in a healthier direction: less smoking, healthier diets, and more leisure-time physical activity. This has been the case in Finland. In the NIS, one objective is to identify the real modern Western lifestyle trend as the healthy one. The aim of collaboration should be to help countries through an unhealthy period as well and as quickly as possible. Some Practical Actions That Can Be Taken Although each country must ultimately find its own way to better public health, the public health situation in the NIS is alarming. Improvement is in the interest of all—not least neighboring countries such as Finland. The international collaboration described here has already resulted in rich and positive experiences. On the basis of the comparative data and those experiences, the following suggestions are made for adaptation to the situations in other countries. In the long run, a feasible and reliable information system is a cornerstone for positive development. It is needed for sound planning of activities and for evaluation and monitoring of any progress. In Estonia and Lithuania, information systems are well on their way to being established; in other NIS countries, this is not the case. In addition to better mortality statistics, repeated population surveys on chronic disease risk factors, health behaviors, and other related determinants, such as nutrition, are badly needed. For effective national action, political support and commitment are of vital importance. Political uncertainty and acute problems make it difficult for decision makers to emphasize long-term planning, such as that needed for chronic disease prevention. On the other hand, effective political decision making requires awareness and demand from the people. This is not yet the case in many of the NIS countries. Thus, preventive health work should focus not only on government action, but also on health communication and mobilization of the people. The experience of the North Karelia Project, as well as that of many other countries, shows that a major national demonstration program can be a strong tool for national chronic disease prevention and health promotion. It can provide for the development and testing of methods on a small scale prior to national implementation. It can also be a strong mechanism for demonstration, inspiration, and training for national purposes. Such a program draws the attention of the media and attracts politicians. Instead of theoretical arguments, reference can be made to the practical and visible experiences of the demonstration project: "Prevention is possible, and it works."

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--> Use of a major demonstration program is also useful in a context of scarce resources and multiple problems, especially in larger countries. If scarce resources can be concentrated in a rather limited area, useful initial experiences and results can be achieved. As for the content of such interventions, initial health information campaigns are needed. There still is, and probably will be for the next few years, a lack of accurate information on risk factors and on the best advice for disease prevention and health promotion. However, in the near future, other activities toward risk reduction should receive major emphasis. To be effective, health communication should go hand in hand with the launching of practical preventive activities in the community and with increased communication among individuals. Even if chronic disease prevention goes far beyond health services, those services—and especially primary health services—are a cornerstone of disease prevention in the community. In this regard, there is a need for profound change in most of the countries of former Soviet Union. The old Soviet system emphasized the work of doctors and the health system in treating diseases. The responsibility of the citizen was not emphasized, nor was the role of public health nurses. People should be reminded of the old wisdom: "Nobody can take better care of your health than yourself." There is a need for a whole range of practical guidelines for risk factor control that are appropriate to the situation and needs of the country in question. Such guidelines should cover measurement techniques, information systems, and modern commonly agreed-upon reference values. Quality control systems, in areas such as cholesterol laboratory analyses, need to be established as well. In spite of the profound role of health services, general community organization for health should be a goal. In the NIS countries, as in every community, there are many public and nonpublic organizations that can be involved in health work. Many citizens' organizations (e.g., health, sports, and women's organizations) can be useful partners in new preventive programs. Schools are useful and effective centers for spreading innovations in many countries. Local media are often interested in practical local health work. A major goal of preventive health work is to make it easier for people to make changes that reduce risk. Achieving this goal necessitates public decisions, such as smoking policies, and supportive action from business and industry. Especially important is the role of the food industry. Healthier food choices should be developed and marketed. This change depends partially on the health consciousness and demand of consumers, but health authorities and health programs can also foster such development. Health concerns can be a central point in national decision making, as well as in international collaboration, for example, in decisions on investments and taxation. Certainly when Western support helps build up the tobacco and dairy industries, the public health consequences are seen for decades to come.

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