Joensuu and the North Karelia Project

Joensuu
The city of Joensuu (pronounced "youn-soo") is a modest town of 75,000 people in the region of North Karelia.

The Non-Communicable Disease Seminar participants, Seth, and I traveled by train for five hours (440 km) north through large pines forests and fresh white snow to North Karelia. One could easily confuse this place for a town in northern Minnesota and I suppose that's why the Finns and Swedes settled in Minnesota - they were good lumberjacks, they could survive the cold winters, and they love to ski!
The first day in Joensuu, we visited the headquarters of the newspaper, Karjalainen. They are the largest daily newspaper and reach over 80% of the population in the area everyday. "How can that be?" you might ask, well the Finns not only consume the most coffee per capita, but they read print newspapers the most too - 34 minutes daily per person! They have 32 daily newspapers and 166 non-daily in a country of only 5.4 million people. They told us about the partnership that they have with the North Karelia Center for Health to promote healthy behaviors and develop a "reality" show of 8 people trying to be healthier - quitting smoking, exercising more, and eating more fruits and veggies. They use journalistic flavor to appeal to the readers and promote healthy lifestyles.

(Katie standing outside the Joensuu City Hall where our international crowd met the Mayor and Regional Council members.)

Hospital visit
Next we visited a primary health center which was very nice but only had 10 clinicians for 150 beds and none who worked the night shift. Not sure I'd ever want to get seen there but alas, they assured us that nurses take on a lot more responsibility here and manage most of the chronic disease management and screening visits and that most of the beds are long-term beds, aka nursing home type, and have six-month waiting lists. A doctor is available by phone and all emergencies are transfered to the Central Hospital in the next town where specialists were covering 24/7. Nurses and doctors are civil servants here, like teachers and politicians, and are not compensated well. Most doctors in this area work in private practice.

Taxes
The Finns spend 46% of their income on taxes! However, they spend half as much as we do ($2331 vs. $5401 per capita) on healthcare per capita. Nearly 100% of babies are born in hospitals and their infant mortality rate is the second lowest in the world to Norway. Healthcare is mostly free in Finland ($12 per visit and minor medication fees). The school system is amazing! They are one of the most literate countries in the world and their schools include a free home-made balanced lunch for all students up to grade 9, free transportation if you live over 3 miles away, and free university tuition. All of their teachers must have a Masters in Education.

Folk singing
That night, the Finnish Heart Association invited us to a special meeting in the next town over. While we were on the bus, I got a phone call from my Dad who had attended my Match Day Ceremony where I found out that I matched at the University of Washington - Seattle for Internal Medicine. I was giddy waiting for the call and nearly in tears when we found out because we were so happy!! When we arrived at the meeting, we were greeted by a choir and soloist who sang "songs about the heart" they said. There were speeches in Finnish by the president of the association, our hero in cardiovascular disease prevention, Pekka Puska, and the town leaders. Then, we had to stand in front of everyone and introduce ourselves and afterwards a few people came up to us but did not speak any English so we had to pull over one of the Finnish participants to translate. It was a great evening and Seth and I celebrated with our new Australian, Nigerian, Bahranian, and Finnish friends over dinner and wine in the hotel afterwards!

(Photos will be posted later)

Back in Helsinki

Helsinki is the northernmost urban area of a population over 1 million, and there is much to do and see in terms of it's design business and history, starting with the centrally located Senate Square and Lutheran Cathedral. The master of the Finnish Art Nouveau was Eliel Saarinen (1873–1950), whose architectural masterpiece was the Helsinki central railway station and the city hall in Joensuu (photo from above).

If it's too cold, you could always spend a day getting lost while shopping in the eight-floor department store, Stockmann's!

St. Petersburg

Seth did not mention how wonderful the styles of the women is here - furs, furs, black tights and boots! Men are dressed in less stylish but still warm fur hats and wool coats, and some even carry leather purses. It's wonderful and cracks me up every time we leave the hotel. More blogs to follow about the Hermitage who's director once said "We can't say we are the #1 art museum in the world, but we aren't #2." We plan on spending all day there tomorrow. Thanks for reading!

Helsinki

Appropriately, I sit in a café with a cup of coffee writing this, my first*, blog post. I say appropriately as the Finns consume more coffee per capita than any other nation in the world (Katie’s colleague opined that it must be due to self-medication to deal with the long dark winters). Our trip began last week with the shortest 9 hour flight I have ever taken – it went by quickly and before we knew it, we were in Paris waiting for our connecting flight to Helsinki. (One side benefit of having to follow my wife around the world was earning status on Delta. The status has allowed me to book exit row seating – which was a godsend for my long legs.) We arrived in Helsinki on Friday afternoon and Katie and I explored the city that weekend before her training started.

Helsinki is a small compact city which made the site seeing quite easy – what has not made the site seeing so easy are the layers of ice and water on the sidewalks. For some reason most buildings do not remove that from their sidewalks, and the city’s solution is to throw down small rocks to help you gain traction. It was a bit odd at first, but after a fall free weekend that must be some reason to that madness.

Katie and I packed in a lot in those days going to museums, visiting markets, exploring the City on self-guided walking tours, and taking the ferry to Suomenlinna – the City’s Maritime Fortress. Helsinki is a great starting point for our trip as English is widely spoken, the City is small and intimate, and we can get our “traveling to foreign land” legs under us. In addition, we learned a lot about the history of the region, a history I was very ignorant of before coming here. For example, did you know that Helsinki was considered Axis-Lite? While they didn’t fight alongside the Nazis, they did receive arms for allowing the Nazis to move through Finland to occupy Norway. Due to this assistance, as war reparations Finland lost a large portion of Karelia to Russia.

(notice all the ice in the bay)

(KTP keeping her eye out for the pesky Russians)

One downside to this trip is traveling during the tourist offseason. Time and time again I have been thwarted as many museums, parks, and tourist sites are closed for repairs or to change exhibitions. This has been frustrating, and hopefully we don’t run into that issue in such a major way again.

We are off this afternoon to Joensuu as part of Katie’s training. The trip is about 440 kilometers and about halfway from Helsinki to the Arctic Circle. By looking at maps, I am guessing that it will look a lot like northern Minnesota - plentiful lakes amid the pine/spruce trees. We come back on Friday, and then head to St. Petersburg on Saturday.

* As this is my first post, there are still some blogger.com nuances I need to figure out. One are pictures and possibly appropriate sizing - so please bear with me.

Making the healthy choice the easy choice

*Seth will be giving you an update on Helsinki tomorrow, this is just a quick update on my seminar.

The Non-communicable Disease Training Seminar in Helsinki, Finland is fantastic! I highly recommend it to anyone who is interested in public health and population-based interventions for chronic diseases. It is based on the North Karelia Project that took a truly population-based approach to treat cardiovascular disease (CVD) in a population of lumberjacks and farmers that were dying at a young age of CVD. They were the folks who claimed, "Veggies are for rabbits" and said "I'll have some bread with my chunk of butter, kiitos (thank you)" who consumed 40 pounds of butter per year! Therefore, their diet (and tobacco use) contributed to their high cholesterol, blood pressure and mortality rates in the 1970s. Simple interventions - smoke-free workplace campaigns, margarine for butter, substituting skim milk for whole milk in schools, increased vegetable subsidies and consumption, and increased physical activity - made a dramatic difference for this community.

Who are we?
I am one of two people from the USA attending the seminar, which thankfully is held in English. There are 24 of us who come from all over he globe: Tanzania, Ethiopia, Thailand, Iran, Finland, Japan, UK, Australia, Bahrain, and the USA. The goal of the seminar is to discuss theories and share ideas for us to bring back to our countries or institutions in order to promote prevention. Specifically, the World Health Organization has emphasized four factors: tobacco, diet, exercise, and alcohol use. I've said it before, but let me re-emphasize, the global burden of cardiovascular disease is HUGE! Eighty percent of all CVD is in developing countries. The costs of pain and suffering from both chronic and infectious diseases are disproportionately affecting the poor. Many of the deaths from these causes are avertable - either preventable or treatable. Building cath labs is not going to solve this problem. Prevention is the only sustainable, affordable, and feasible public health intervention that has been shown to decrease this epidemic and decrease other chronic disease as well as delay or post-pone mortality so that people can live more healthy, productive lives and contribute to development and decreasing poverty in their countries. Often, the factors that contribute to disease are outside of the control of the individual and are deeply rooted in society (socioeconomic, cultural and environmental factors).
Get Healthy Before Wealthy
Some argue that helping get people out of poverty - for example, providing clean water, sanitation, and education - would improve their health so why bother with chronic disease management? Well, the truth is development is slow to decrease poverty and not real effective for improving health. If we help strengthen the health systems and make people healthier now, they in turn will do more to help improve development and decrease poverty.
In a nutshell
How to start a prevention program? First, involve the stakeholders, policymakers, and community as managers and directors of programs from the beginning. Then, use working groups to try to understand all the health and non-health existing resources and challenges in the community. Then, target the primordial, primary and secondary interventions using medical and social behavioral methods. Examples include individual behavorial changes like quitting smoking to lifestyle changes in the community, like smoke-free campaigns. Improving nutrition, encouraging physical activity, and improving medication adherence for treatment of disease are also important interventions. Finally, building infrastructure to treat the high risk people in the community.
"Make the healthy lifestyle the easy one."
Successful programs are those that are multi-dimensional, target the whole population, complement initiatives in place, are sustainable, and have adequate time and funding to complete the intervention(s). In all cases, making the healthy lifestyle or behavior the easier choice is key for a sustainable and effective intervention program. If only we could do this in the US too!
"Only those who see the invisible can do the impossible."