REACH, PFOA and teflon

It will be interesting to see how REACH, the new European chemicals policy, deals with PFOA, the main component of Teflon; indeed, how it deals with Teflon itself
PFOA, perfluoroctanic acid, is the main component in the making of Teflon, the non-stick, heat resistant, highly useful and versatile fluoropolymer used in countless industry and household products. PFOA is made at DuPont , West Virginia , at a site next to the Ohio river , the Mississippi ’s largest tributary
DuPont have long denied any links between elevated rates of cancer and exposure to chemicals at its plants, but the company has also attracted the attention of negative research. A great amount of this has focused on PFOA.
Local residents living downstream from the DuPont plant have had their water supplies contaminated by PFOA for fifty years, and say that local paediatricians report a manifold higher than average rate of early childhood caries – where children’s adult teeth fall out at 12.
James Dahlgren, a California toxicologist, has found a statistically significant excess of prostate, breast and cervical cancers compared to the US average in both plant workers and residents.
I recently interviewed Kathie Ball, 52, who has had three cancers after working on the production line at DuPont for 10 years. She was eventually fired after complaining of sexual harassment – her supervisor wanted to touch her silicone breasts – and because she had taken too much time off. Since this time off was due to the cancers she had contracted, this is a rather cheeky complaint. Kathie sounded like one of life’s victims, a former homecoming queen and high school cheerleader whose chief character trait was to be too trusting and chose the wrong job because it was well paid.
Activists I spoke to in West Virginia say that the heavy concentration of chemicals firms in this rural, hilly, indeed beautiful Appalachian state find it convenient that its population is relatively poor, unconnected, ill-educated.
DuPont have moved on criticisms: last year they settled a $100 m class action law suit with 80,000 local residents, without however admitting liability.
The Environmental Protection Agency has launched its own lawsuit against DuPont for failing for two decades to report health risks associated with PFOA.
The sum will be settled in January and could amount to as much as $300m, the largest corporate environmental fine in US history. Earlier this year, the EPA said PFOA was a likely human carcinogen. There has been a lot of US media coverage about this, with many headline puns on the themes of criticism “sticking” and DuPont being “in the frying pan”.

How does this relate to REACH? Neither DuPont US nor DuPont UK return calls. But according to a source in the green movement who has connections with the working group that classifies chemicals into the groups of high concern, PFOA is imported into Europe in quantities of about 100 tonnes a year, where, presumably, locally, it is made into teflon. Because of the ridiculous way that the tests for toxicity under REACH that have to be carried out are dependent only on individual amounts made by each producer, imported by each importer, PFOA could be quantified according to the 1 – 10 tonne range – if there are, say, 11 importers.
This is the lowest quantity range band, and requires provision to the EU chemicals agency of the absolute minimum of data – such as boiling point - unless the chemical in question has been classified as carcinogenic, mutagenic or harmful to reproduction.
Only then will the substance be subject to further tests and possible authorisation.
REACH is based on self assessment – the chemicals industry might call it an “invitation to commit suicide”. A commission source says the company itself has to determine and state whether a substance is carcinogenic, based on definitions in a previous EU directive. But on further examination this argument is circular, because that too talks about carcinogenic without defining it further.

Question: is DuPont going to call PFOA carcinogenic?

Supposing it doesn’t. its low quantities, and low risk also means companies would be given the longest possible deadline to register PFOA – 11 years – and, as said, could well escape the need for authorisation altogether.
There is a provision for the commission to check suspect dossiers; and it may do so for PFOA – because DuPont is a big company, PFOA is on the greens’ hitlist, star attraction of their alarming brochures, and because of articles like this. DuPont may also declare PFOA as a carcinogen. Then, another question poses itself
Teflon is a polymer; and polymers are blanket exempted from need for registration at all. It is also generally believed to be harmless. <<<<<<<<<<<<<<<<<
However, there is increasing American evidence that the Teflon used in greaseproof wrapping under the brand name zonyl comes off in small amounts during eating and enters the stomach. The stuff is used in hamburger wrappers.
In the stomach it degrades i7nto PFOA, findings by US scientists show. A Teflon carpet spray meanwhile that impregnates carpets against stains and spills is believed to contain alcohol residues of PFOA- alcohol which evaporate easily into the atmosphere – and are likely to enter the lungs of babies crawling around the house. According to Canadian scientist Scott Mabury, head of chemistry at Toronto university, under atmospheric action it also degrades into PFOA, which is why the chemical is found in the blood of polar bears in the arctic, albeit in tiny concentrations. Toxicologists say that PFOA’s advantage, the strong carbon fluorine bonds that give it its anti stick, heat resistant properties, also makes it one of the most persistent chemicals on the planet. One American chemicals campaigner said morosely of this entirely manmade chemical: “When mankind and all our civilisation has come and gone, this will be our pathetic signature. Aliens arriving on the planet in the distant future will know this as Earth’s PFOA age.” Even the much-malign PCBs, already banned, degrade slowly.
PFOA may not - unlike at the DuPont plant – enter the average European’s body in sufficiently dangerous quantities to be banned.
It will be interesting to see what happens next- how the EU deals with it. DuPont is subject to another lawsuit, in Florida . The plaintiffs are calling for five billion dollars to replace the planet’s pots and pans.

Caravanes medicales

In the old days, caravans used to carry salt and
slaves across the Saharan wastes. These days, they
carry medicine

It is perhaps hard to believe of western Europe’s
nearest neighbour. Despite a relatively peaceful
recent history, within eyeshot of Spain and strong
links to France, Morocco’s social indicators -
literacy and school enrolment - and health indicators
- infant mortality, say - are astonishingly poor --
even by Arab standards. According to WHO, mothers are
fives times as likely to die in childbirth as in
Tunisia; and children have a fifty percent greater
chance living to the age of five. Syria, hardly a
poster boy of progressivism, has half the infant
mortality and a quarter of the rates of tuberculosis..
The figures are bad because Moroccans score poorly on
another social statistics, that of access to care,
where the discrepancies with comparable Arab countries
are as bad, if not worse, leading for instance, to
many women choosing traditional midwives for births.
Lebanon, despite being long racked by civil war, still
manages to have five times as many doctors and has ten
times as many dentists.
Jordan has five times has many pharmacists and three
times as many trained nurses per capita. And these
countries are small, while Morocco is large and with a
heavy concentration of such care there is around the
northern coastal cities, making effective
discrepancies in access to trained medical staff for
large parts of the population even worse, compared to
its Arab cousins.
Groups of urban Moroccan doctors from the francophone
urban elite, fed up with their country’s poor record
on access, have recently taken matters into their own
hands. The elites of Casablanca and Rabat, elegant,
European, the most modern parts of Morocco, have
sometimes seemed to indulge its guilt in frivolous
campaigns such as civil society caravans, even fashion
caravans, bringing culture and political knowhow to
the regions for a weekend or two But inspired by
these a caravan movement of doctors has been launched,
whose benefits have turned out to be far more
substantial. Convoys of trucks and buses have with
filled with doctors from areas where they are most
concentrated - the big cities - and they have been
moved out to the provinces for weekends at a time to
carry out their duties free of charge in the remotest
desert areas of Morocco, where normally there might be
just one doctor per ten thousand population..
One of the leading lights of the so-called caravanes
medicales idea has been Dr Abdel El Hairy, 48, who
began the project after his father left a bequest to
build a village school and well. The Moroccan
bureaucracy insisted that any gift had to be
channelled through an NGO, and so he started one, AMI,
whose initials stand for locales in his father’s home
region. With money left over, the NGO funded a weekend
expedition, with three doctors, who carried out ten
consultations, in the local village hall. Since then
the idea of roughing it for a few days out of social
responsibility has grown hugely in popularity.
Word got out on the doctors’ grapevine, in Casablanca,
Morocco’s commercial capital and richest city, and
the numbers increased. Helped by French charity money,
which paid for the drugs, the most recent excursion,
in July, some sixty urologists, obstetricians,
dermatologists, gynecologists, paediatricians and
other doctors – many wealthy, with private clinics in
Casablanca - joined the caravan. In the evenings, they
had food cooked by berber women and compared rare
pathologies under the stars; in the daytime, they
carried out consultations – lots of cases of
tuberculosis, child meningitis; cancer of the uterus,
in adult males, skin and eye problems, were common.
They saw over three thousand in three days – in
chaotic conditions, with nomads arriving on camels
from a radius of dozens of kilometres away, and
patients queuing for hours .


Traditional cure

For what is the healthcare alternative for these
deprived Moroccans? In the company of some Casablanca
journalists, I went to see what an example of the
traditional medicine many Moroccans use, in the
impoverished Casablanca suburb of Hay Mohammadi.
Islamic parties are strong here, mainly because
Islamic activists have fulfilled some of the role of
the welfare state for the poor residents. Here, being
the city, there is theoretical access to medicine,
unlike the desert. But, in a country where 20 percent
of the population earns less than a dollar a day, few
can afford to have a basic consultation with a state
doctor, let alone a private one So they rely on
traditional doctors, the hajjamas - in the same way
the desert nomads are usually forced to do, though in
their case it is lack of access.
The traditional doctors work from shed-like workshops
on the edge of the quarter, and they seem to have one
cure-all treatment: la saignee, the bloodletting,
using crude instruments.. They often double as
barbers, and that is also an alibi.
Mohammed, aged 60, had teeth that did not look like a
brilliant advertisement for hygiene and care. At first
he denied he worked as a doctor, “I only did this in
the past”. (The practice is allegedly illegal). But
soon he confessed with a smile: “I still have to work
because my children are lazy. My son just smokes hash
all day.” With a colleague in another shop he was then
quite keen to show how the saignee worked. . The
patient – usually elderly - sits in the barber’s
chair in front of a mirror, the usual hair dressing
bric-a-brac – lotions, razors. Always a portrait of
Hassan II and his son Mohammed VI, past and present
kings. After partaking in several cups of mint tea,
his hair is ritually shaved, a 5cm incision is made in
the back of the head (cheeks if a woman) and blood is
withdrawn by attaching a pipe like object to the back
of the head. sucking produces a vacuum which draws
blood into the receptacle. “It cures everything,” said
Mohammed said confidently.
Others are less convinced. One Moroccan journalist,
Rida Addam, medical correspondent for Le Matin
newspaper, described to me witnessing another saignee
nearby: a 78-year-old night guard entered a nearby
shop with his twenty something son, who was clearly
sceptical.
As tea was prepared, the son angrily told Addam about
the way he was spoken about by the hajjama. "I tell my
father that this won’t cure his health problems.. But
the hajjama just says 'does Little Mohammed want some
tea, as if I was still the little boy he once
circumcised'."
He sighed deeply, ignoring the glances of pity from
the two elders, and finally rose to leave. His father
wished him good luck, and then proceeded to have the
blood letting. Ten minutes later he rose, looking
rather weak, said Addam. “One is always under the
protection of saints,” affirmed the “doctor”, one of
Mohammed’s many colleagues in the area. The old man
staggered out, accusing his son of “lacking faith”,
while the doctor cleaned his equipment in preparation
for another patient.

Mobile hospital

It is clear that the caravanes medicales play a useful
role in those areas they can are able to cover. They
make the role of the local hajjama redundant, even
carrying out circumcisions. “Entirely voluntarily,”
said one urologist, who normally runs a clinic off the
fashionable boulevard Hassan II. “And safer.”
Fortunately their popularity as caught on – not just
in numbers within caravans, but the number of regular
caravan projects has now grown to about twelve,
including one comprised of dentists, Enfant Sourire,
(Child’s smile.). Each dentist will see up to 50
patients a day.
The caravan concept itself is beginning to move on,
too – thanks to another Moroccan expatriate Dr Hassan
Zahouani, a professor in Lyon.
Until now, the projects have worked out of the largest
building in the village, or in tents if in desert. But
from next June a prototype mobile hospital, a 450
square metre structure that can be set up and
dismantled in hours, will be ready. Its design will
be modular, adaptable to different demands, reducible
into smaller-sized units, says Zahouani, who once
worked for the European Space Agency and was inspired
by
the modular design of the international space
station, Sponsored by the French firms Dassault, a
defence contractor, and L’Oreal, the cosmetics firm,
the 1m euro hospital will be made of covered steel
especially adapted to the desert’s extreme conditions
and have laser-equipped operating theatres to deal
with that scourge of the UV-rich desert, cataracts,
which have already made 150,000 Moroccans blind. The
hospitals could also be useful for other desert areas,
Iraq say, said Zahouani.


Western Sahara

All good? It might be churlish to raise any criticism
of all these projects, given that access to health in
Morocco is so poor. The projects have been lauded in
Morocco’s francophone media. But if a small criticism
may be made a foreign critic might note that, in the
choice of places to visit, the ostensibly independent
caravans have chosen, unwittingly or not, destinations
that further the government’s political agenda.
Tafilalet for instance, where the hospital will
circulate, is uncontroversial, because it has always
been part of Morocco. But several caravans have
visited the Morocco-controlled Western Sahara, where
the Polisario armed independence movement has been
agitating for independence on behalf of the ethnically
different Sahrawis since 1975. The area is secured,
and so is safe for NGOS. Here the caravans have been
helping the Sahrawi people, showing up the contrast
with the many refugees displaced by the Moroccan army
into Algeria in 1975, and have spent all their lives
in that country, in refugee camps, under terrible
conditions. Morocco may need to win hearts and minds:
a UN peace process, which looks as if it will restart
after dormancy, is trying to broker an agreement that
would lead to a referendum on the future final status
of western Sahara..
Providing health is perhaps one means of killing
yearning for independence by kindness, in the same way
the government has provided the western Sahara with a
superior road and buildings infrastructure, though
leaving the area undermedicalised..
The caravans' effects given absence of other
healthcare may be good, but could the help dispensed
be interpreted as an endorsement of the brutal way
Moroccan government deals with relatively peaceful
expressions in favour of independence?
Just two months ago, a Moroccan court jailed 12
Western Saharan separatists, handing out sentences of
up to eight years for charges including “vandalism,
resisting arrest and joining an armed crowd”. The
activists were among fifty arrested in May when
demonstrating for independence. The conflict is
complex and by no means black-and-white.
The world’s longest serving prisoners of war, 404
Moroccan ex soldiers, were released a few weeks ago by
Polisario having been held captive for an appalling 20
years in detention camps in southern Algeria. Yet the
sense of injustice at the arrest is clearly enormous:
12 have recently (14 September) been transferred into
hospital after having been on hunger strike for over
five weeks.
It is difficult to get a straight answer on this, part
of the circumspection comes from the need for local
military logistics cooperation, partly because, I
suspect, doctors I spoke to, like many in their
profession, just want to get away from politics and do
their jobs. Yet politics is there all the same.

The future

The caravans, for all the help they give, are clearly
not a sole solution, since they reach relatively few
people, thousands rather than millions.
But the government seems to be doing something. “The
new king, Mohammed VI, who is just 37, really cares
about the people,” said one doctor. “He really wants
to help poor communities.” In the support of this
statement, the doctor pointed to the king – whose
power is great in Morocco – launching a slum clearance
programme as one of the key priorities of his reign.
Meanwhile the health ministry says has looked at
medical caravans as a possible model for public funded
similar action in rural areas. There will be an
extension of health insurance, assurance de maladie,
from five to ten million – though that will still
leave 20 million Moroccans without health insurance..
The national literacy campaign has doubled its
efforts, targeting women, whose literacy rate is a
modest 38 per cent, the third worst in the muslim
world, after Afghanistan and Somalia.
This illiteracy is said to result in women still using
traditional midwives - because of apparent ignorance
rather than lack of money, since one of the few perks
of the poor is to have free births in hospital. The
Islamic family code is being replaced by laws that ban
child brides and put partners on an equal footing in
the hope that empowered women hold the key to rural
health education – though established practices are
hard to abolish with the stroke of a pen. The health
budget, insists the government, has risen by ten
percent a year since 2002.
Zahouani disputes the rosy picture, saying the
government stil lacks a serious strategy for dealing
with its rural communities.. Other doctors say that,
though health spending may have increased, it has been
inexpertly targeted: the capping of doctors’ salaries
as a proportion of the health budget has led to
doctors being put out of work, emigrating to France,
and leaving newly built hospitals being closed.
Both government and its critics might agree though
that, whether developments are going in the right
direction or not, Morocco still has a long way to go
before catching up with the rest of the Arab world.
“We had no oil money, but that is no real excuse. We
also had an elite that was only interested in fighting
for and securing well-paid public sector jobs, no
entrepreneur class, as in Lebanon, interested in
creating wealth. No one paid attention to rural
poverty,” said one doctor. “The neglect will take a
long time to be put right.”
One small positive side to the neglect, though, has
been that Morocco has pioneered a concept that has
tentatively been copied in other undermedicalised,
large countries, Egypt for instance. But the concept –
both the caravan andn the mobile hospital – deserves
to be spread even further, says El Hairy – Afghanistan,
perhaps, or Sudan, if those countries ever achieved piece.
In Morocco, meanwhile, the caravans keep rolling on.

The heart healer

Pekka Puska was born in Vaasa, northern Finland, in 1945. He was director of the North Karelia Project in eastern Finland from 1972 to 1997. Between 2001 and 2003 he was director of the department of non-communicable disease prevention at the World Health Organization in Geneva, Switzerland. He has a PhD in epidemiology and has published more than 400 scientific papers. He has also served as a member of the Finnish parliament. He is married with two young children

Why North Karelia?

In the 1970s North Karelia had the highest mortality rate from heart disease in the world. The local governor signed a petition to the government demanding that something be done about it. At the time I was a young assistant in the department of public health in Turku. I had degrees in political science and medicine. I was also a member of President Urho Kekkonen's Centre party - he was one of my heroes, he had many radical ideas.
I had been active in student politics, and was president of the national students' union. I was part of the generation that all over the world wanted more democracy - in Finland there were riots in 1968. The Centre party was strong in rural areas. In 1972, as a result of the petition, Kekkonen sent me and other young researchers to North Karelia.

What was it like?

North Karelia is a remote, cold, rural area on the Russian border. Finland had had a very difficult second world war, fighting the Russians. The country was poor; it was not the "Nokia country" you see today.
But in the 1950s and 1960s, people started to dream of a better life. Before the war, their diet had been simple and healthy. People died mainly of infectious diseases. After the war, people started to eat more and more dairy products. They had more money. In 1972, a typical meal in North Karelia consisted of high-fat dairy products and sausages. Anything green was dismissed as "animal food".
I said to people: "You are eating as if every day was Sunday." When I went to the province, one-third of the young children had fathers who had died of chronic heart disease.

So what did you do?

Our researchers discovered that most risk factors came from the environment and from lifestyle. The Finnish focus at the time was very much on hospital treatment - the old cardiological establishment was very sceptical of our approach. I told North Karelians to reduce saturated fats, salt, meat and sugar, and to add fibre, bread, vegetables and fruit. "What is the difference between fruit and vegetables?" I asked them. They defined fruit as "something you import". They said eating fruit would not be supporting Finnish agriculture.
Our policy was "boots deep in the mud": really going deep into the rural communities. I visited dairy farmers and lumberjacks and tried to persuade them to adopt a diet low in saturated fat. I encouraged them to diversify into crops such as berries and apples. We had to visit them many times to persuade them. People said: "Why deny us our small pleasures?" But one sausage maker who had had a heart attack agreed to make sausages out of mushrooms instead of pork. And I persuaded one bakery owner to halve the salt content in his bread, and switch to vegetable oil instead of animal fat.

How did you get the message through at the community level?

We went to churches, where priests were very supportive of us. We stood in supermarkets issuing health leaflets. We had a non-smoking pledge in schools, for which pupils promised not to smoke for a year. Community competitions featured cooking courses and the local grocer was asked to persuade customers to buy fewer sausages and to cook with vegetable fat instead of animal fat. I also worked with small companies to develop juices and jellies. At the housewives' organisation called Marta, I organised recipes using less salt, more vegetables, lower fat. And I told housewives to start substituting low-fat milk for high-fat. When their husbands complained, I said they should pour low-fat milk into high-fat containers and serve this at the breakfast table, which they did.

How did people take to your campaign?

I was on a weekly TV programme that measured the blood pressure of 10 North Karelians. The series was very popular and ran for 15 years. It became a talking point - people all over Finland followed it. When a new episode was about to air, people would say, "Dr Puska, I'm curious. Has that girl from the previous show managed to stop smoking?" I remember after one of these programmes a Helsinki bus driver stopped his vehicle and called me up to the front. He took a cigarette packet from his shirt pocket, crushed it and put it in my hand. Then he said: "That was my last cigarette."
A lot of people did not realise there was a connection between blood pressure and heart disease. I introduced yellow cards for every health clinic visitor, and every time patients visited a doctor or nurse they took a new reading and entered the new figure on their card. It was a simple step but it enabled people to take control of their lives. People used to show me their cards in the street and were very proud.
I have a collection of newspaper cartoons about the project. One has a waiter pointing to a customer at a table and telling another waiter, "Make sure he doesn't try to sneak his own salt into the food." The joke is funnier if you appreciate that Finns used to smuggle small bottles of spirits into restaurants and pour them into their drinks.

Did all this effort pay off?

Between 1972 and 1997, when the North Karelia project ended, the number of deaths from coronary heart disease dropped by 82 per cent. Life expectancy among men went up eight years, from 65 to 73. Blood cholesterol in the population dropped 20 per cent. It was like putting the whole population on cholesterol-reducing drugs. The consumption of fruit and vegetables went from the lowest in Europe to the highest in northern Europe. In 1972, 90 per cent of the population put butter on their bread; now only 7 per cent do. Salt consumption halved. Smoking went down drastically among men, though it increased among women. In Finland as a whole, between 1969 and 2002 deaths from chronic heart disease dropped by 76 per cent among men aged 35 to 64. People used to come up to me and shake my hand and say, "Thank you Dr Puska, you have saved my life." It amused me. Perhaps health experts are the modern priests.

And people lost weight?

We never targeted weight or calories. These were big men in hard-working physical occupations from farming communities. Finland's body mass index - a measure of body fat based on height and weight - has remained constant among women and risen a little among men in the past 30 years.

Would deaths have dropped even more if you'd also had a weight-loss programme?

Coronary heart disease is the biggest global killer today. The greatest risk factor is high blood pressure, and that has nothing to do with obesity. Cholesterol, the second biggest risk factor, is slightly related to obesity. Smoking, the third-biggest contributor, has nothing to do with obesity. Obesity is a sign that diets are going wrong, and not itself a cause of ill health. Weight-reduction programmes that aim just to lose weight without changing diets are a waste of time.

Have any of your family suffered heart disease?

My father had a heart attack when he was 45. He changed his lifestyle and lived to be 80.

Is anyone trying to do what you did in North Karelia? Can it be done elsewhere?

Over the years I have helped to develop pilot projects in Tianjin in China, the island of Mauritius, Valparaiso in Chile, Isfahan in Iran and Nizwa in Oman, after their health experts came to Finland to study the North Karelia project. Nowadays it is much more difficult to do what I did. In the International Journal of Epidemiology in 1973 they described what I was doing as "shotgun prevention". They said I was using mass action without evidence. Nowadays everything has to be evidence-based.
These countries had some of their own challenges. For example, how can women get enough exercise if they have to wear veils? And exercise is difficult in countries where summer temperatures are more than 50 °C. The Chinese had serious problems with hypertension because soy sauce is high in salt; they started using low-salt sauce in schools. In Mauritius they eat a lot of unhealthy palm oil so the government encouraged use of sunflower oil instead.
“My father had a heart attack when he was 45. He changed his lifestyle and lived to be 80”

Did it work for them?

The pilot projects led to a drop in coronary heart disease. But the real problem is translating a pilot project into a national project: getting industry and business to collaborate in developing and selling healthy foods, getting non-governmental organisations and the media to promote healthy living. In this, other countries have been less successful: they are much bigger than Finland. We have had a lot of interest from western European countries such as the UK but these societies are much more heterogeneous than ours. On the other hand, they are more open to new ideas. North Karelia was a very traditional area, hostile to innovation. Campaigners have to use the specific strengths of each culture to push through their goals.

What has happened in Finland recently?

The fall in the Finnish heart disease rate has levelled off and has a long way to go: we are still only average in Europe. Joining the European Union in 1995 affected things: our schools went from low-fat milk to high-fat because the EU paid farmers subsidies for high-fat milk. But in the past few years the EU has been positive at promoting restrictions on tobacco smoking. Today it is harder to change people's habits because there are many more lifestyle choices: more TV channels, for example, and too much choice of processed and high-fat food in the supermarkets. But the global food industry is increasingly on my side - the guy who said hello to me just now is a very senior director at Nestlé. That company realises that healthy foods can be profitable.

What do you remember most about your time in North Karelia?

Visiting farmers in the snow and wind at -40 °C. I remember an elderly man in a small village near the Russian border who came to me after my talk and said: "Doctor, I have a question: you keep telling us what kind of fat we should use on our bread. You never tell us if what I put on my bread is healthy or not." What do you put on your bread, I asked. "Bear's fat," he replied.

The heart healer

Pekka Puska was born in Vaasa, northern Finland, in 1945. He was director of the North Karelia Project in eastern Finland from 1972 to 1997. Between 2001 and 2003 he was director of the department of non-communicable disease prevention at the World Health Organization in Geneva, Switzerland. He has a PhD in epidemiology and has published more than 400 scientific papers. He has also served as a member of the Finnish parliament. He is married with two young children

Why North Karelia?

In the 1970s North Karelia had the highest mortality rate from heart disease in the world. The local governor signed a petition to the government demanding that something be done about it. At the time I was a young assistant in the department of public health in Turku. I had degrees in political science and medicine. I was also a member of President Urho Kekkonen's Centre party - he was one of my heroes, he had many radical ideas.
I had been active in student politics, and was president of the national students' union. I was part of the generation that all over the world wanted more democracy - in Finland there were riots in 1968. The Centre party was strong in rural areas. In 1972, as a result of the petition, Kekkonen sent me and other young researchers to North Karelia.

What was it like?

North Karelia is a remote, cold, rural area on the Russian border. Finland had had a very difficult second world war, fighting the Russians. The country was poor; it was not the "Nokia country" you see today.
But in the 1950s and 1960s, people started to dream of a better life. Before the war, their diet had been simple and healthy. People died mainly of infectious diseases. After the war, people started to eat more and more dairy products. They had more money. In 1972, a typical meal in North Karelia consisted of high-fat dairy products and sausages. Anything green was dismissed as "animal food".
I said to people: "You are eating as if every day was Sunday." When I went to the province, one-third of the young children had fathers who had died of chronic heart disease.

So what did you do?

Our researchers discovered that most risk factors came from the environment and from lifestyle. The Finnish focus at the time was very much on hospital treatment - the old cardiological establishment was very sceptical of our approach. I told North Karelians to reduce saturated fats, salt, meat and sugar, and to add fibre, bread, vegetables and fruit. "What is the difference between fruit and vegetables?" I asked them. They defined fruit as "something you import". They said eating fruit would not be supporting Finnish agriculture.
Our policy was "boots deep in the mud": really going deep into the rural communities. I visited dairy farmers and lumberjacks and tried to persuade them to adopt a diet low in saturated fat. I encouraged them to diversify into crops such as berries and apples. We had to visit them many times to persuade them. People said: "Why deny us our small pleasures?" But one sausage maker who had had a heart attack agreed to make sausages out of mushrooms instead of pork. And I persuaded one bakery owner to halve the salt content in his bread, and switch to vegetable oil instead of animal fat.

How did you get the message through at the community level?

We went to churches, where priests were very supportive of us. We stood in supermarkets issuing health leaflets. We had a non-smoking pledge in schools, for which pupils promised not to smoke for a year. Community competitions featured cooking courses and the local grocer was asked to persuade customers to buy fewer sausages and to cook with vegetable fat instead of animal fat. I also worked with small companies to develop juices and jellies. At the housewives' organisation called Marta, I organised recipes using less salt, more vegetables, lower fat. And I told housewives to start substituting low-fat milk for high-fat. When their husbands complained, I said they should pour low-fat milk into high-fat containers and serve this at the breakfast table, which they did.

How did people take to your campaign?

I was on a weekly TV programme that measured the blood pressure of 10 North Karelians. The series was very popular and ran for 15 years. It became a talking point - people all over Finland followed it. When a new episode was about to air, people would say, "Dr Puska, I'm curious. Has that girl from the previous show managed to stop smoking?" I remember after one of these programmes a Helsinki bus driver stopped his vehicle and called me up to the front. He took a cigarette packet from his shirt pocket, crushed it and put it in my hand. Then he said: "That was my last cigarette."
A lot of people did not realise there was a connection between blood pressure and heart disease. I introduced yellow cards for every health clinic visitor, and every time patients visited a doctor or nurse they took a new reading and entered the new figure on their card. It was a simple step but it enabled people to take control of their lives. People used to show me their cards in the street and were very proud.
I have a collection of newspaper cartoons about the project. One has a waiter pointing to a customer at a table and telling another waiter, "Make sure he doesn't try to sneak his own salt into the food." The joke is funnier if you appreciate that Finns used to smuggle small bottles of spirits into restaurants and pour them into their drinks.

Did all this effort pay off?

Between 1972 and 1997, when the North Karelia project ended, the number of deaths from coronary heart disease dropped by 82 per cent. Life expectancy among men went up eight years, from 65 to 73. Blood cholesterol in the population dropped 20 per cent. It was like putting the whole population on cholesterol-reducing drugs. The consumption of fruit and vegetables went from the lowest in Europe to the highest in northern Europe. In 1972, 90 per cent of the population put butter on their bread; now only 7 per cent do. Salt consumption halved. Smoking went down drastically among men, though it increased among women. In Finland as a whole, between 1969 and 2002 deaths from chronic heart disease dropped by 76 per cent among men aged 35 to 64. People used to come up to me and shake my hand and say, "Thank you Dr Puska, you have saved my life." It amused me. Perhaps health experts are the modern priests.

And people lost weight?

We never targeted weight or calories. These were big men in hard-working physical occupations from farming communities. Finland's body mass index - a measure of body fat based on height and weight - has remained constant among women and risen a little among men in the past 30 years.

Would deaths have dropped even more if you'd also had a weight-loss programme?

Coronary heart disease is the biggest global killer today. The greatest risk factor is high blood pressure, and that has nothing to do with obesity. Cholesterol, the second biggest risk factor, is slightly related to obesity. Smoking, the third-biggest contributor, has nothing to do with obesity. Obesity is a sign that diets are going wrong, and not itself a cause of ill health. Weight-reduction programmes that aim just to lose weight without changing diets are a waste of time.

Have any of your family suffered heart disease?

My father had a heart attack when he was 45. He changed his lifestyle and lived to be 80.

Is anyone trying to do what you did in North Karelia? Can it be done elsewhere?

Over the years I have helped to develop pilot projects in Tianjin in China, the island of Mauritius, Valparaiso in Chile, Isfahan in Iran and Nizwa in Oman, after their health experts came to Finland to study the North Karelia project. Nowadays it is much more difficult to do what I did. In the International Journal of Epidemiology in 1973 they described what I was doing as "shotgun prevention". They said I was using mass action without evidence. Nowadays everything has to be evidence-based.
These countries had some of their own challenges. For example, how can women get enough exercise if they have to wear veils? And exercise is difficult in countries where summer temperatures are more than 50 °C. The Chinese had serious problems with hypertension because soy sauce is high in salt; they started using low-salt sauce in schools. In Mauritius they eat a lot of unhealthy palm oil so the government encouraged use of sunflower oil instead.
“My father had a heart attack when he was 45. He changed his lifestyle and lived to be 80”

Did it work for them?

The pilot projects led to a drop in coronary heart disease. But the real problem is translating a pilot project into a national project: getting industry and business to collaborate in developing and selling healthy foods, getting non-governmental organisations and the media to promote healthy living. In this, other countries have been less successful: they are much bigger than Finland. We have had a lot of interest from western European countries such as the UK but these societies are much more heterogeneous than ours. On the other hand, they are more open to new ideas. North Karelia was a very traditional area, hostile to innovation. Campaigners have to use the specific strengths of each culture to push through their goals.

What has happened in Finland recently?

The fall in the Finnish heart disease rate has levelled off and has a long way to go: we are still only average in Europe. Joining the European Union in 1995 affected things: our schools went from low-fat milk to high-fat because the EU paid farmers subsidies for high-fat milk. But in the past few years the EU has been positive at promoting restrictions on tobacco smoking. Today it is harder to change people's habits because there are many more lifestyle choices: more TV channels, for example, and too much choice of processed and high-fat food in the supermarkets. But the global food industry is increasingly on my side - the guy who said hello to me just now is a very senior director at Nestlé. That company realises that healthy foods can be profitable.

What do you remember most about your time in North Karelia?

Visiting farmers in the snow and wind at -40 °C. I remember an elderly man in a small village near the Russian border who came to me after my talk and said: "Doctor, I have a question: you keep telling us what kind of fat we should use on our bread. You never tell us if what I put on my bread is healthy or not." What do you put on your bread, I asked. "Bear's fat," he replied.