Editorial |
The Finnish dance of death: impressions from Helsinki
Johan P. MackenbachDepartment of Public Health, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, the Netherlands
Correspondence: Johan P Mackenbach, Department of Public Health, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, the Netherlands, e-mail: j.mackenbach{at}erasmusmc.nl
The annual meetings of the European Public Health Association provide good opportunities for experiencing different European cultures, and in October 2007 we all went to Helsinki to see what makes Finland special. Its very high density of public health researchers perhaps? The very slow, very cautious manner of speaking of many of its inhabitants, including researchers? Or the Finnish successes in systematically lowering cardiovascular disease mortality?
This is all true and all very special, but Finns are also special in another field, the field of Dances of Death. First of all, they have the most northerly of all painted Dances of Death—a late-medieval form of art that was popular during the 15th and 16th centuries throughout continental Europe, but only rarely reached the northern borders of European civilization. The one and only Finnish Dance of Death is located in Inkoo, a small town 70 km to the East of Helsinki. It resembles the one and only Estonian Dance of Death, located across the Botnic Gulf in Tallinn, probably because both followed the example of the famous Dance of Death of the Hanseatic town of Lubeck in Germany.1
Dances of Death depict the living, ordered by social position from high to low, while they are being taken away in a lethal dance by a skeleton, the personification of Death, who reproaches them for their sins. Dances of Death depict social inequality, but their message is one of equality of all before death, and of the necessity for all to repent in order to avoid being condemned to eternal hell.2
In the late middle ages, higher placed persons actually had lower mortality rates than lower placed persons, as they do now. Socio-economic inequalities in mortality exist in all European countries, but particularly in Finland where differences in mortality are larger than in many other European countries, both on a relative and on an absolute scale.3 This is an amazing finding, not only because Finland has such successful public health policies, but also because Finland has pursued egalitarian social and economic policies for decades. As a result of progressive taxation and an extensive social security system, Finland has had the lowest extent of income inequality of all European countries since the 1970s.4 Despite all these policies, Finland has not succeeded in reducing inequalities in mortality below the level seen in other European countries.
A full explanation has so far eluded Finnish and European public health researchers, but it appears that social variations in excessive alcohol consumption are part of the explanation. In many (but not in all) countries, binge drinking and other forms of excessive alcohol consumption are more frequent in lower socioeconomic groups, and contribute to the explanation of inequalities in mortality, through higher rates of causes of death directly related to alcohol (such as various forms of cancer, liver cirrhosis, and injuries) and of causes of death indirectly linked to alcohol (such as ischemic heart disease). But in Finland the contribution of excessive alcohol consumption to inequalities in mortality seems to be larger than elsewhere.5
Why? This alcoholic dance with death is as fatal as it is puzzling. In Eastern Europe, including the Baltic states and Russia, similarly fatal patterns of alcohol intoxication are found, and have been linked to demoralization and other psychosocial effects of the political and economic changes since the fall of the Soviet empire. But this cannot apply to Finland, a country which has been peaceful and prosperous for decades, and which takes good care of the more vulnerable sections of its population.
It is perhaps more likely that what we see here is an interaction between social inequality and national cultures which are permissive of alcohol intoxication, and provide all those who so desire an easy, but potentially fatal escape from the boredom and frustration of everyday life, which is particularly prevalent among the less-well-off. Eliminating this Dance of Death is one of the great challenges for public health research in Finland, and will require innovative interventions and powerful policies. It would be great if Finland's public health community would succeed in finding a solution.
References
1 Dietl C. Wovon sich hier keiner fernhalten kann. Accessed 30 October 2007. Zum Totentanz in Lubeck, Tallinn and Inkoo. Available at: http://www.helsinki.fi/lehdet/uh/199g.htm.
2 Mackenbach JP. Social inequality and death as illustrated in late-medieval death dances. Am J Public Health (1995) 85:1285–92.
3 Mackenbach JP, Kunst AE, Cavelaars AEJM, et al. Socioeconomic inequalities in morbidity and mortality in Western Europe. Lancet (1997) 349:1655–9.[CrossRef][Web of Science][Medline]
4 WIDER World Income Inequality Database. Accessed 27 October 2007. Available at: http://www.wider.unu.edu/wiid/wiid.htm.
5 Makela P, Valkonen T, Martelin T. Contribution of deaths related to alcohol use of socioeconomic variation in mortality: register based follow up study. Br Medl J (1997) 315:211–6.
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