The Miracle Pill

by Peter Walker

  It took place in North Karelia, the fairly remote Finnish region of which Joensuu is the capital, which at the start of the 1970s was among the poorest parts of the country, heavily reliant on agriculture and forestry. At the time, North Karelia had the highest coronary mortality rate in Finland, which in turn had the worst such record in the world. An enormously high proportion of those who died were men, often in middle age. Something had to be done, Finnish officials decided. In late 1971, they formed a committee tasked with finding ways to turn this around. The main investigator, sent to the region with a mandate to save lives, was Peska.

  ‘I became involved as a very young doctor,’ he recalls. ‘At that time it was a crazy, crazy idea. In North Karelia, our problem at that time was not obesity or physical inactivity, because people were farmers and lumberjacks – physically very active. But the diet was absolutely crazy. Enormous amounts of animal fat and dairy fat, practically no vegetables, no fruit, and also enormous amounts of smoking. Those were our problems. But the principles are still the same: how to influence human behaviours, in individuals or in population-wide behaviour.’

  The years of work led by Peska and his team essentially wrote the modern guidebook for how to transform public health. At one level, there was – after some persuasion – significant political help, with Finland passing early legislation to restrict smoking, including a ban on all tobacco advertising in 1976. The other element was a huge programme of public information material, and endless other ways to cajole, persuade or otherwise urge people – mainly the men, in this case – in North Karelia to stop smoking and change their diets.

  From just 1972 to 1977, Peska’s team pumped out material for 1,500 newspaper articles, about one a day, and distributed almost 100,000 Father’s Day cards carrying healthy messages. On smoking, they ran ‘quit and win’ contests. They arranged a cholesterol-lowering competition between two villages, only for forty villages to decide they wanted to take part. The winning community saw average adult cholesterol levels fall by 11 per cent in just two months. At the same time, local authorities tried to help farmers move away from the dairy-based agriculture dominant in the region, providing support for them to grow berries instead.

  By any imaginable metric, the long-term results were stunning. In slightly over three decades the annual age-adjusted cardiac death rate among men aged thirty-five to sixty-four, the main target for the work, dropped by 85 per cent in North Karelia. Death rates for many cancers, not least for ones related to smoking, also fell significantly, as did overall mortality rates for both genders. Other figures were equally impressive. The male smoking rate fell from 52 per cent to 31 per cent. The proportion of people who routinely spread butter on their bread went from more than 80 per cent to below 10 per cent, while the numbers of men who ate vegetables virtually every day increased four-fold.6

  Peska is impatient with the idea that the success was in some way a result of a distinctive Finnish culture in which people are particularly receptive to official advice. ‘When I speak about this in other countries, very often the comments are, “Oh, that’s easy for you because the Finns are such nice people; it won’t work for us”,’ he tells me. ‘But the obstacles were enormous in the ’70s. Changing human behaviour is difficult everywhere. And there’s no magic bullet. This was all new. When we said we wanted to do community-based prevention with heart disease, the cardiologists said, “What the hell are you talking about? Community-based prevention? We don’t even know how to prevent it among individuals.” But the thing is that if you want to change behaviours, it has to be changed in society, with the physical and social environment, and I think that’s critical also for physical activity.’

  Peska says that during the 1990s, as researchers started to see more overweight people, they realised that with patterns of work changing, physical inactivity was becoming a new problem. And despite the immeasurably more healthy diet, BMI levels rose over the period of the project.

  He snorts when I mention the ‘nanny state’ objection raised by British politicians over such lifestyle-based policies. ‘It’s a terrible statement,’ he fumes. ‘You can still behave as you want. But you just have the support to have a healthy lifestyle. Most smokers would like to stop. Most overweight people would like to lose weight. So it is giving support to people to do things that they want. And when you speak about the nanny state, we must also remember children. I don’t think they should have free choice. I think it is the role of schools and society to guide children.’

  In terms of lessons for other countries, the North Karelia project particularly highlights two elements. One is the vital importance of community buy-in, making sure people know why it is a good idea for the project to succeed. For example, Peska’s team worked closely with housewives’ associations, given at the time it was almost always the women of a household who bought and prepared all the food. Reaching the housewives was also important because while the men saw smoking as a rare pleasure in a generally deprived area, it was the families who experienced the aftermath of so many early male deaths.

  A 1990s report into the project, co-written by Peska, reprints a series of heart-rending letters sent to the public health team from bereaved local women, with one describing heart disease as ‘our family curse’. Another wrote to tell the researchers that her husband had died of a heart attack: ‘He had one five years ago, followed by two more; the third one took him. He was a heavy smoker, which certainly contributed to it and damaged his heart. I hope that this project can bring understanding and help to many, so that people do not have to lose their health at their best age.’7

  The other lesson is the need for complete political support. Peska, who went on to become a politician himself for a period, among many other later roles, says this took time. ‘Gradually, when things started to move, politicians became more interested,’ he says. ‘We got the tobacco legislation very early, some rules about food production. So policy is important. But how do you move politicians? That comes back to the media. I’ve been a member of parliament twice, and rational arguments are obviously important, but what really moves politicians is when they see that voters are moving. The voter is the king.’

  Some Finns do understandably grumble about what can be the country’s arguably sanitised international reputation as a paradise of universally excellent education and equality, presided over by a caring government which promotes public health. They point to serious social problems, not to mention significant political divisions illustrated by the rise of the True Finns, the populist right-wing, anti-immigrant party who are now the second-biggest force in parliament, if nonetheless shut out of the coalition in which Krista Kiuru serves.

  But almost fifty years on from the start of Pukka Peska’s work, it seems clear that the politicians have listened to him. Kiuru tells me the North Karelia project was seen as ‘a challenge’ to the rest of the country, and that the political consensus has very much been changed. Even the True Finns support the interventionist approach to public health, she says.

  There is similar near-unanimity over other policies, such as the €500 million spent every year on providing free, nutritious meals to every schoolchild, which was Kiuru’s responsibility in a former role as education minister. She recalls how one MP objected to the cost. She responded by taking him to eat one of the meals. Seeing how healthy and tasty it was, he changed his mind. ‘This is something which is carrying Finland towards the future,’ she says. ‘It will save us money in the long term. It is investing in people, investing in kids. Finns are basically quite motivated taxpayers – if they can see that there is a greater good which will come from it.’

  The mention of tax is important. If Finland’s example tells us anything, it is that the big changes need the sort of resources that can only really come from central government. In 1980, Finland passed what was known as the Sports Act, giving significant central funding for new sports facilities and creating local officials to oversee the process. A central registry of sports
sites now lists about 30,000 venues – one for every 175 or so Finns. An updated Sports Act in 1999 expanded the scope to more everyday physical activity, providing money for cycle routes and small local parks.8

  A lot of the efforts around activity are focused on young people – it is no coincidence that the Winter Cycling Congress opened at a primary school. In the last chapter we heard about Finnish Schools on the Move, a government programme to increase movement among young people, for example with active lessons, or the option for pupils to stand as they learn.

  In Joensuu, I meet Joonas Niemi, one of the lead coordinators from Finnish Schools on the Move, who is there to discuss promoting active school travel. Year-round across Finland about 65 per cent of children walk or cycle to school, a figure which rises to 80 per cent outside winter.9 He is talking at the Winter Cycling Congress about a project in which his team lent cameras to students to film their bike rides to and from school, so they could point out places on the route they found worrying or unsafe. Inside schools, the goal is to add an hour of physical activity to every school day, including movement in lessons.10

  A strand of Finnish Schools on the Move, known as Joy in Motion, sends teams into kindergartens to help teachers promote activity. Nina Korhonen, a former kindergarten teacher who leads the project in the education ministry, says it is as much about changing attitudes as anything else. ‘It doesn’t really cost much,’ she tells. ‘How much does it cost to have children running around? It doesn’t need anything big. You just need to get the teachers to change their approach. When I was trained as a teacher we were taught to keep the children quiet. We tell them it’s good for the kids to run around.’11

  Sanna Ojajärvi is yet another public employee who is paid to get young people moving. Her work with the Network of Finnish Cycling Municipalities, a cross-council group promoting active travel, involves spreading the bike message in schools and kindergartens, including children as young as three. With younger children, she says, the best promotion is games, such as one where she blows bubbles and they have to cycle through and catch them. ‘What the teachers are afraid of is the kids just messing around,’ Ojajärvi says. ‘But usually nobody falls. And if a small kid falls off it’s perfectly normal – if you learn how to cycle, of course you’ll fall off. But it’s not dangerous.’12

  Trying to reset childhood

  Finland is not the only country trying to push the pro-movement message for children. Chris Wright is head of wellbeing at the UK’s Youth Sports Trust, and he is as passionate about the subject as any Finn. His organisation runs programmes in nurseries and kindergartens in economically deprived areas of England, promoting movement-based learning, also trying to persuade parents to let their toddlers run around elsewhere. This is hugely important work. If you remember the statistic from Chapter 1, only 9 per cent of British children under five currently meet the age-group recommendation that, once they can walk, they should amass at least three hours of physical activity a day.13

  I had been due to see one of these projects in action at a nursery in Minehead, a coastal town in Somerset, in south-west England. However, the coronavirus lockdown put a stop to this. Wright tells me the area around Minehead has been shown to have England’s lowest levels of social mobility. It is thus a focus for the activity programme, given that movement in the early years of a child’s life has been shown to be key to not just their physical development, but progress in a series of other areas.

  ‘Movement and play in the early years can help to develop literacy, language communication, building relationships, and being more confident individuals,’ Wright tells me. ‘The attributes that children get from playing and moving have a direct correlation then on being able to read, being able to grip a pen, being able to sit down and concentrate on tasks. It’s fundamental to children’s development. If they’re not moving, then, you know, the evidence will tell you that they’re not developing.’14

  Two years of work in nurseries like the one in Minehead have shown ‘a demonstrable difference not just on children’s activity levels, but their language, their ability to form positive relationships and their confidence in their learning and also in who they are’, Wright tells me.

  He is critical of the English school curriculum’s apparent lack of interest in physical development, saying that even in kindergarten settings it can be ‘quite narrow’ and insufficiently play-based. This, he argues, has to change: ‘It’s adults that stop children from moving, and what we’re trying to do is unlock their ability to be able to move, and reset childhood to a certain degree. If these weeks with COVID-19 have taught us anything, it’s that movement is probably more important now than it ever has been. You can have an education system that, of course, educates children to be able to pursue the careers and the life that they want, but they also need the fundamentals of wellbeing in order to be able to achieve that. I think that’s the message that’s slowly starting to creep across the system.’

  Talking to Wright is inspirational. But there is one glaring difference between his efforts, however persuasive and effective, and the work done by people like Nina Korhonen and Joonas Niemi. They are civil servants, part of a system of government specifically geared towards creating activity in everyday life. In contrast, the Youth Sports Trust is a charity. By the standards of many charities it is relatively well funded, with an overall income last year of £11.6 million, a mixture of government grants and sponsorship. But in national terms, even for just one aspect of public health, such a sum is virtually an irrelevance. It amounts to just under 0.02 per cent of the budget of the Department for Education,15 against whose more instinctively anti-movement approach the charity often campaigns. If ministers gave Wright an official post with a bigger budget, sufficient political backing and enough time, I’m sure he could transform the physical future for the UK’s children. But at the moment it’s just not a fair fight.

  It is a contrast you see again and again when you examine the approach to tackling inactivity in places like the UK, as against centrally led programmes as seen in Finland, or even with the decades of consistent spending on and support for cycle infrastructure in the Netherlands and Denmark. There are British success stories, but as with the exemplary work of Chris Wright, and the Daily Mile, which we saw in the preceding chapter, they are invariably private or charitable enterprises, reliant on occasional official help or, as with the Daily Mile, the largesse of a multinational company as sponsor.

  Another notable example of this is Parkrun, the weekly 5km mass run which since starting in 2004 has spread both across the UK and to dozens of other countries, and now claims 3 million participants worldwide. Parkrun is fascinating in that it is an ostensibly sports-based event – a timed run over a set distance – which has nonetheless developed a culture which makes it welcoming to participants ranging from elite athletes to previously inactive first-timers, as well as those who simply volunteer.

  Parkrun started life as the Bushy Park Time Trial, set up by keen runner Paul Sinton-Hewitt as primarily a social event, since at the time he was injured and had depression. From a single venue in southwest London and a first outing involving thirteen runners and three volunteers, it has expanded into a near-ubiquitous feature of parks on a Saturday morning, run by an associated charity which is heavily involved in wider physical activity efforts.

  Chrissie Wellington, Parkrun’s head of wellbeing, says that despite the name, it is less a race than what she calls ‘a community-led social event centred on activity’. She explains: ‘What is central is that Parkrun can be anything you want it to be. And that’s really, really important. People consume Parkrun in many different ways. Some just come along for the post-event coffee; others see it very much as a time trial and are using it either as a target event or as a means to achieve a target time in a race. So the timed element is an important part of Parkrun. And competitiveness with oneself or with others can be important. But it is not the central kind of raison d’être of Parkrun, as it might be for o
ther physical activity.’16

  You cannot simply turn up to a Parkrun. Participants, whether running or volunteering, must register on a website and bring a printed barcode, which is scanned each time they take part. This creates a huge database of who takes part and how often, and how fast they go if they run. Because the registration form includes a question on current activity levels, this also tracks those who change their lifestyles. Part of Wellington’s role is to use these statistics to try to make Parkrun better at reaching more people, as well as having to deal with the fifty-plus annual requests from academics and universities wanting to use Parkrun’s database for research projects.

  There are now around 6 million people signed up, even if more than half never make it to an event. The data, Wellington says, shows the event is attracting lots of people who are ‘starting out on their journey to being active’, with up to 7 per cent saying they are totally immobile when they register. ‘Evidence suggests those that are less active are not only increasing their activity through Parkrun but are increasing their activity outside of it,’ Wellington says.

  The benefits are even seen in volunteers, whose duties often involve them walking greater distances than they would usually, and who then can end up being more active in other aspects of their lives. There is evidence, Wellington says, that the volunteers see the biggest life changes of anyone: ‘It really does show us that involvement in Parkruns isn’t simply beneficial due to walking or running at the event, and that volunteering is as important, if not more.’