The Finnish Allergy Program 2008-2018: Society-wide proactive program for change of management to mitigate allergy burden

A 10-year national program to improve prevention and management of allergic diseases and asthma was implemented in Finland (population 5.5. million) in 2008-2018. The main aim was to reduce the long-term burden of these conditions. The strategy was changed from traditional avoidance to tolerance and resilience of the population. Health was endorsed instead of medicalization of mild symptoms. Disease severity was reevaluated, and disabling clinical manifestations were given high priority. For health care, 5 quantitative goals and 1 qualitative goal were set. For each of the goals, specific tasks, tools, and outcome evaluation were stipulated. During the program, 376 educational sessions gathered 24,000 health care participants. An information campaign targeted the lay public, and social media was used to contact people. In the 10 years of the program, the prevalence of allergic diseases and asthma leveled off. Asthma caused fewer symptoms and less disability, and 50% fewer hospital days. Food allergy diets in day care and schools decreased by half. Occupational allergies were reduced by 45%. In 2018, the direct and indirect costs of allergic diseases and asthma ranged from €1.5 billion to €1.8 billion, with the 2018 figures being 30% less than in the respective figures in 2007. The Finnish proactive and real-world intervention markedly reduced the public health burden of allergic disorders. The allergy paradigm was revisited to improve management with systematic education. A 10-year national program to improve prevention and management of allergic diseases and asthma was implemented in Finland (population 5.5. million) in 2008-2018. The main aim was to reduce the long-term burden of these conditions. The strategy was changed from traditional avoidance to tolerance and resilience of the population. Health was endorsed instead of medicalization of mild symptoms. Disease severity was reevaluated, and disabling clinical manifestations were given high priority. For health care, 5 quantitative goals and 1 qualitative goal were set. For each of the goals, specific tasks, tools, and outcome evaluation were stipulated. During the program, 376 educational sessions gathered 24,000 health care participants. An information campaign targeted the lay public, and social media was used to contact people. In the 10 years of the program, the prevalence of allergic diseases and asthma leveled off. Asthma caused fewer symptoms and less disability, and 50% fewer hospital days. Food allergy diets in day care and schools decreased by half. Occupational allergies were reduced by 45%. In 2018, the direct and indirect costs of allergic diseases and asthma ranged from €1.5 billion to €1.8 billion, with the 2018 figures being 30% less than in the respective figures in 2007. The Finnish proactive and real-world intervention markedly reduced the public health burden of allergic disorders. The allergy paradigm was revisited to improve management with systematic education. Allergy is a systemic, immunologic, and heterogenous disorder, with variable organ manifestations that change during the life span. They cause a fair amount of disability and costs both for individuals and for society. There are no reports of coordinated action plans to combat allergic conditions in a defined population. In Finland (population 5.5 million), several successful national public health programs to control respiratory diseases have been completed.1Erhola M. Vasankari T. Jormanainen V. Toppila-Salmi S. Herrala J. Haahtela T. 25 years of respiratory health in Finland.Lancet Respir Med. 2019; 7: e16Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar The Finnish Asthma Program 1994-2004 was successful and deployed in many countries.2Selroos O. Kupczyk M. Kuna P. Łacwik P. Bousquet J. Brennan D. et al.National and regional asthma programmes in Europe.Eur Respir Rev. 2015; 137: 474-483Crossref Scopus (64) Google Scholar The latest action plan, the Finnish Allergy Program 2008-2018, was initiated to further reduce the burden on individuals and society by emphasizing prevention. The Finnish Allergy Program was based on an extensive review3von Hertzen L.C. Savolainen J. Hannuksela M. Klaukka T. Lauerma A. Mäkelä M.J. et al.Scientific rationale for the Finnish Allergy Programme 2008-2018: emphasis on prevention and endorsing tolerance.Allergy. 2009; 64: 678-701Crossref PubMed Scopus (54) Google Scholar of the new knowledge regarding immune regulation and the importance of nature relatedness.4Ege M.J. Mayer M. Normand A.C. Genuneit J. Cookson W.O. Braun-Fahrländer C. et al.GABRIELA Transregio 22 Study Group. Exposure to environmental microorganisms and childhood asthma.N Engl J Med. 2011; 364: 701-709Crossref PubMed Scopus (1044) Google Scholar, 5Hanski I. von Hertzen L. Fyhrquist N. Koskinen K. Torppa K. Laatikainen T. et al.Environmental biodiversity, human microbiota, and allergy are interrelated.Proc Natl Acad Sci U S A. 2012; 109: 8334-8339Crossref PubMed Scopus (628) Google Scholar, 6Lynch S.V. Wood R.A. Boushey H. Bacharier L.B. Bloomberg G.R. Kattan M. et al.Effects of early-life exposure to allergens and bacteria on recurrent wheeze and atopy in urban children.J Allergy Clin Immunol. 2014; 134: 593-601Abstract Full Text Full Text PDF PubMed Scopus (259) Google Scholar, 7Haahtela T. Laatikainen T. Alenius H. Auvinen P. Fyhrquist N. Hanski I. et al.Hunt for the origin of allergy - comparing the Finnish and Russian Karelia.Clin Exp Allergy. 2015; 45: 891-901Crossref PubMed Scopus (92) Google Scholar The main aim was to transform the strategy from avoidance to tolerance and resilience. It focused on allergy health (ie, having a good life despite allergies). Reducing unnecessary treatments and measures was important, especially in children and families. Severe allergy and asthma were given attention. Goals for health care, such as standardizing diagnostics,8Heinzerling L. Frew A.J. Bindslev-Jensen C. Bonini S. Bousquet J. Bresciani M. et al.Standard skin prick testing and sensitization to inhalant allergens across Europe-a survey from the GALEN network.Allergy. 2005; 60: 1287-1300Crossref PubMed Scopus (202) Google Scholar halving the prevalence of food allergy diets, and reducing the total costs of allergic diseases and asthma by 20%, were set. The program has now been completed, and it represents a successful change management initiative at the country level. In this review, we present the program's main outcomes and discuss the possibilities of scaling up the experience for other countries and extending it into the future. In Finland and globally, the incidence of asthma and allergic diseases has been increasing for decades.9Haahtela T. Lindholm H. Björksten F. Koskensuo K. Laitinen L.A. Prevalence of asthma in Finnish young men.BMJ. 1990; 301: 266-268Crossref PubMed Scopus (227) Google Scholar,10Bach J.F. The effect of infections on susceptibility to autoimmune and allergic diseases.N Engl J Med. 2002; 347: 911-920Crossref PubMed Scopus (1978) Google Scholar Currently, 30%-40% of Finnish schoolchildren and young adults appear to be sensitized to 1 or more common allergens.11Ruokolainen L. Paalanen L. Karkman A. Laatikainen T. von Hertzen L. Vlasoff T. et al.Significant disparities in allergy prevalence and microbiota between the young people in Finnish and Russian Karelia.Clin Exp Allergy. 2017; 47: 665-674Crossref PubMed Scopus (65) Google Scholar The problem was already discernible in the 1980s, when the first allergy management guideline in Finland was published,12Ministry of Social Affairs and Health, Helsinki, Finland, A statement of an allergy commission. 1983;28;1-105 [in Finnish and Swedish].Google Scholar and also in 1998, when a consensus report was prepared.13The Finnish Medical Association Duodecim and the Academy of Finland 1998. Allergic population – allergy as a publich health problem. Consensus Meeting in Hanasaari 11.11.1998, pp 1-189 [in Finnish].Google Scholar The numbers of patients with allergy and asthma grew in the 1990s, and neither children nor adults received satisfactory allergy care. The 10-year Finnish Asthma Program was based on new information on asthma, primarily as an inflammatory disease.14Haahtela T. Järvinen M. Kava T. Kiviranta K. Koskinen S. Lehtonen K. et al.Comparison of a beta 2-agonist, terbutaline, with an inhaled corticosteroid, budesonide, in newly detected asthma.N Engl J Med. 1991; 325: 388-392Crossref PubMed Scopus (672) Google Scholar In a relatively short period, management was improved and costs were reduced by better early diagnostics and by turning from β2-agonists to inhaled corticosteroids as the first-line medications.15Haahtela T. Tuomisto L.E. Pietinalho A. Klaukka T. Erhola M. Kaila M. et al.A 10 year asthma programme in Finland: major change for the better.Thorax. 2006; 61: 663-670Crossref PubMed Scopus (302) Google Scholar,16Haahtela T. Herse F. Karjalainen J. Klaukka T. Linna M. Leskelä R.L. et al.The Finnish experience to save asthma costs by improving care in 1987-2013.J Allergy Clin Immunol. 2017; 139: 408-414Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar But the main problem of how to prevent asthma and allergic diseases in the first place remained. At the population level, avoidance and fear of all exposure leads to (1) an increased need for treatment, (2) social consequences such as isolation and impairment of daily living, and (3) even serious allergic reactions if exposure (eg, to foods) occurs unexpectedly. Avoidance of allergens is always important for individual patients, especially in cases of severe food allergy, but it requires justified grounds and better-defined time limits. Concern and medicalization became visible as new allergy day care centers, allergy schools, and allergen-free working environments were demanded. At the same time, large trials indicated that the avoidance of allergens to prevent clinical symptoms may not be feasible in the long term.3von Hertzen L.C. Savolainen J. Hannuksela M. Klaukka T. Lauerma A. Mäkelä M.J. et al.Scientific rationale for the Finnish Allergy Programme 2008-2018: emphasis on prevention and endorsing tolerance.Allergy. 2009; 64: 678-701Crossref PubMed Scopus (54) Google Scholar Psychosocial factors should also be addressed, as they play an important role in patient decisions and adherence to treatment. Tolerance and resilience are immunologic, psychological, and societal.17Haahtela T. Anto J.M. Bousquet J. Fast and slow health crises of Homo urbanicus: loss of resilience in communicable diseases, like COVID-19, and non-communicable diseases.Porto Biomed J. 2020; 5: e073Crossref PubMed Google Scholar The allergy paradigm was revisited, and loss of immune balance was regarded as more important than any possible new risk factor. At the population level, endorsing tolerance, especially in children, adolescents, and families, was regarded as central.18Pelkonen A.S. Kuitunen M. Dunder T. Reijonen T. Valovirta E. Mäkelä M.J. et al.Allergy in children: practical recommendations of the Finnish Allergy Programme 2008-2018 for prevention, diagnosis, and treatment.Pediatr Allergy Immunol. 2012; 23: 103-116Crossref PubMed Scopus (33) Google Scholar A major change of attitude was needed among health professionals, patients, and the lay public. To be effective at a public health level, a program needs to change management and have a societal impact. In this review, the program is presented according to the classical change management model of Kotter,19Kotter J. Leading change. Harvard Business School Press, Boston, Mass1996Google Scholar as an example for many other noncommunicable diseases. Allergic diseases are a model of a life course approach, as they often start at birth and usually persist throughout life. A 10-year program was planned, implemented, and monitored to change the management strategy at the national level to care pathways centered around the patient. Health professionals needed help to adapt new ideas and improve the provision of care, patients needed to be involved for shared decision making, and the lay public needed to be informed. This was achieved in close collaboration with policymakers (the Finnish Institute for Health and Welfare) to provide a new national strategy and create grounds for future initiatives. Allergy management is split into several specialities in the medical discipline. The position of allergology as a main speciality, subspeciality, or additional training courses varies from one country to another. In most countries, a coordinated public health approach to management of allergies is lacking. Are specialists providing support for general practitioners and for those working at the grassroots level? Do private sector and public health professionals have the same goal? Overall, allergy services seem widely inadequate.20Diwakar L. Cummins C. Lilford L. Roberts T. Systematic review of pathways for the delivery of allergy services.BMJ Open. 2017; 7e012647Crossref PubMed Scopus (21) Google Scholar Finland was no exception, with cooperation being problematic both between primary and secondary care and between different specialities. However, Finland's small population with a relatively high level of education and well-organized public health care established a population management model and took steps from treatment to prevention. After a consensus meeting involving clinicians with different specialities, epidemiologists, nutritionists, immunologists, patients, citizens, and health officials, a group of experts prepared the 10-year program, which was launched in April 2008 (see Fig E1 in this article's Online Repository at www.jacionline.org).21Haahtela T. von Hertzen L. Mäkelä M. Hannuksela M. Allergy Programme Working GroupFinnish Allergy Programme 2008-2018 - time to act and change the course.Allergy. 2008; 63: 634-645Crossref PubMed Scopus (124) Google Scholar,22Bousquet J. Bieber T. Fokkens W. Kowalski M. Humbert M. Niggemann B. et al.In Allergy, 'new day has begun'.Allergy. 2008; 63: 631-633Crossref PubMed Scopus (15) Google Scholar The coalition continued as a program steering group. The organization was kept simple and without hierarchies. Strategies were chosen, and goals were set. The key messages targeted all citizens (Table I). For health professionals, 6 goals (5 of which were quantitative) and indicators were tailored (Table II). Each goal had its specific tasks, tools, and evaluation methods. The tasks were the activities or the targets in pursuing the goal (what to do), and the tools were those used to perform the tasks (how to do it). The outcomes were evaluated and verified. The program linked allergy not only with clinical disease but also with allergy health. Mild symptoms, especially in childhood, were regarded as a normal immune development and not as a reason for special guidance or intervention.18Pelkonen A.S. Kuitunen M. Dunder T. Reijonen T. Valovirta E. Mäkelä M.J. et al.Allergy in children: practical recommendations of the Finnish Allergy Programme 2008-2018 for prevention, diagnosis, and treatment.Pediatr Allergy Immunol. 2012; 23: 103-116Crossref PubMed Scopus (33) Google ScholarTable IKey messages of the Finnish Allergy Program 2008-2018•Endorse health, not allergy•Strengthen tolerance•Adopt a new attitude to allergy, and avoid allergens only if mandatory•Recognize and treat severe allergies early, and prevent exacerbations•Improve air quality, and stop smoking Open table in a new tab Table IIMain goals and key results of the Finnish Allergy Program 2008-2018Finnish Allergy Program goalsProgram outcomesPotential impact on planetary health1. Prevent allergyIndicator: asthma, rhinitis, and atopic eczema prevalence reduced by 20%Prevalence of allergic rhinitis and asthma leveled off and symptoms decreasedChanges in environment and lifestyle are primary causes of allergic diseases, asthma, and other NCDs. They are largely prevented by nature relatedness, active mobility, and sustainable diet, which have large planetary impacts2. Improve tolerance/resilienceIndicator: prevalence of food allergy diets reduced by 50%-Strengthen immunity by increasing contact with natural environments and by following healthy diets (eg, the traditional Mediterranean or Baltic diet)-Use antibiotics only out of necessityPrevalence of food allergy diets in day care decreased by 43%-65%In Finland, new recommendations regarding healthy diets for families and children were launched in 2019Contact with nature has been improved (eg, in day care by adopting the concept of Nature Step)The biodiversity hypothesis of health should be applied in everyday life-Turn cities green-Conserve and regenerate nature-Use healthy food and sustainable food production for human and planetary health-Protect populations from epidemics of infection (antibiotic resistance)3. Improve allergy diagnosticsIndicator: allergy testing practiced in certified testing centersAll major allergy diagnostic centers have been educated, certified, and auditedQuality control improves patient care, saves societal resources, and reduces the planetary impact on health care4. Reduce work-related allergiesIndicator: incidence of occupational allergies reduced by 50%Incidence of occupational allergies was reduced by 45%Better control of working conditions saves lives, affects quality of life, and increases productivity. It also has a major impact on planetary health5. Focus on severe forms of disease and treat them earlyIndicator: asthma-related emergency department visits reduced by 40%During the program, asthma-related emergency department visits decreased by 6% (by 53% in children), and 35% in the 2000s. Hospital days decreased by 50%, and by 73% in the 2000s.Fewer hospitalizations and medications save societal resources and reduce carbon footprint of health care, with planetary impact6. Reduce allergy and asthma costsIndicator: Allergy costs reduced by 20%Health care and disability costs decreased by 30% (€200 million) in 2018 compared with in 2007Enormous potential for global savings resulting from prevention and better care of individuals with NCDsNCD, Noncommunicable disease.The program's measures are reflected in Planetary Health to illustrate the potential of systematic changes in health care. Open table in a new tab NCD, Noncommunicable disease. The program's measures are reflected in Planetary Health to illustrate the potential of systematic changes in health care. In 2008, the relevance and acceptance of the key messages were tested among 744 health professionals via e-mail (response rate 71%). General practitioners scored "strengthen tolerance" at 9.1 on a scale of 4 to 10.23Haahtela T. Valovirta E. Bousquet J. Mäkelä M. the Allergy Programme Steering GroupThe Finnish Allergy Programme 2008-2018 works.Eur Repir J. 2017; 49: 1-6Crossref Scopus (36) Google Scholar Allergy practice left much room for improvement (eg, the availability of allergen immunotherapy was poor [score 5.4]). The program was implemented through educational and information campaigns that had 2 targets: (1) health professionals and (2) patients, families, and the lay public. In Finland, as in all Nordic countries, the health sector is mainly publicly funded24Saltman RB, Teperi J. Health statistics for the Nordic countries. Nordic Medico-Statistical Committee (NOMESCO), Copenhagen, Denmark 2016;104:1-242.Google Scholar (see The Finnish Health Care System section in this article's Online Repository at www.jacionline.org). The private sector is smaller than the public sector and complements the latter, especially in larger cities. The Finnish Lung Health Association, a nongovernmental organization (NGO) for professionals, was responsible for the education of health care providers (see Table E1 in this article's Online Repository at www.jacionline.org). To improve allergen tolerance, simple guidance was provided (see Table E2 in this article's Online Repository at www.jacionline.org). In 11 years, approximately 24,000 participants from across the country gathered in 376 educational sessions. Two patient NGOs, the Allergy, Skin and Asthma Federation and the Organization of Respiratory Health, with about 60,000 members carried out the information campaign, which targeted patients, risk groups, and the lay public from 2011 to 2015 (see Table E1). For outcome evaluation, the Finnish health care registers provided invaluable data sources, especially the hospital admission register of the Institute for Health and Welfare and the drug reimbursement register of the Social Insurance Institute. For work-related diseases, verified cases are registered by the Finnish Institute of Occupational Health. For outcome evaluation, the baseline period was 2000 to 2010, depending on the survey, source, and method. The Finnish Anaphylaxis Register was established in 2000 at the Helsinki University Central Hospital.25Mäkinen-Kiljunen S. Haahtela T. Eight years of severe allergic reactions in Finland. A register-based report.World Allergy Organ J. 2008; 1: 184-189Abstract Full Text Full Text PDF PubMed Google Scholar Physicians (mostly allergists) from across the whole country voluntarily report cases of severe allergic reactions and causative agents, if identified. A 1-page questionnaire for medical professionals is available on the Internet. Allergy and asthma costs were analyzed from all data sources in collaboration with government officials.26Jantunen J. Kauppi P. Linna M. Martikainen J. Mäkelä M. Pelkonen A. et al.Astman ja allergian kustannukset ovat suuret mutta laskussa [Asthma and allergy costs in Finland are high but decreasing].Finnish Medical Journal. 2014; 69 ([in Finnish; abstract in English]): 641-646Google Scholar The cost analysis included outpatient visits, private physician appointments, occupational health services, hospital days, rehabilitation, and drugs. Disability preventing individuals from working was followed through national registers. Short-term sickness-related absences and reduced working capacity were estimated by a questionnaire survey. The main 10-year outcomes are summarized in Table II. During the program, the prevalence of allergy and asthma in Finnish conscripts leveled off.27Reijula J. Latvala J. Mäkelä M. Siitonen S. Saario M. Haahtela T. Long-term trends of asthma, allergic rhinitis and atopic eczema in Finnish young men: a retrospective analysis, 1926-2017.Eur Respir J. 2020; 561902144Crossref PubMed Scopus (5) Google Scholar In the country's capital Helsinki, the incidence of physician-diagnosed asthma leveled off, and between 2006 and 2016, the incidence of allergic rhinitis decreased slightly.28Hisinger-Mölkänen H. Pallasaho P. Haahtela T. Lindqvist A. Sovijärvi A. Piirilä P. The increase of asthma prevalence has levelled off and symptoms decerased in adults during 20 years from 1966 to 2016 in Helsinki, Finland.Respir Med. 2019; 155: 121-126Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar We attempted to reduce unnecessary food allergy diets in children. In 3 cities (Helsinki, Espoo, and Vantaa [total population around 1.2 million]), the prevalence of allergy diets in day care decreased by 43% in 2 years29Erkkola M. Saloheimo T. Hauta-Alus H. Kukkonen A.K. Virta S. Kronberg-Kippilä C. et al.LILLA study group. Burden of allergy diets in Finnish day care reduced by change in practices.Allergy. 2016; 71: 1453-1460Crossref PubMed Scopus (11) Google Scholar (Fig 1, A). In the rural municipality of Lieto (18,000 inhabitants) in southwestern Finland, the rate of reduction was 65%,30Savolainen J. Mascialino B. Pensamo E. Åberg K.M. Silvan M. Borres M.P. et al.Structured intervention plan including component-resolved diagnostics helps reducing the burden of food allergy among school-aged children.Pediatr Allergy Immunol. 2019; 30: 99-106PubMed Google Scholar and, in some regions, it even reached 80%. No anaphylactic reactions were observed in these settings. To improve the quality of testing, a strategy was devised to standardize skin prick testing. A total of 31 allergy centers that together performed around 90% of all testing in Finland were educated, audited, and certified. Between 2007 and 2016, the number of verified cases of occupational allergic diseases (asthma, rhinitis, allergic alveolitis, allergic and irritant contact dermatitis, protein contact dermatitis, and contact urticaria) fell by 45%. The reduction was not explained by changes in the workforce (Fig 1, B). The preceding Finnish Asthma Program15Haahtela T. Tuomisto L.E. Pietinalho A. Klaukka T. Erhola M. Kaila M. et al.A 10 year asthma programme in Finland: major change for the better.Thorax. 2006; 61: 663-670Crossref PubMed Scopus (302) Google Scholar was effective, and it was expected that the Finnish Allergy Program might not lead to further improvements. In the 2000s, the number of asthma-related emergency department visits decreased by 35% (by 77% in children younger than 5 years), but it decreased by no more than 6% during the new program. However, the number of asthma-related hospital days decreased by 73% in the 2000s and by 50% during the new program (Fig 1, C). In 2000s, the number of patients with asthma who were entitled to reimbursement for regular medication has increased by 40%, indicating improving treatment coverage. Today, asthma causes less severe symptoms than in earlier years. In 2016, 41% of patients with physician-diagnosed asthma had been symptom-free during the previous year (31% in 2006 versus 24% in 1996).28Hisinger-Mölkänen H. Pallasaho P. Haahtela T. Lindqvist A. Sovijärvi A. Piirilä P. The increase of asthma prevalence has levelled off and symptoms decerased in adults during 20 years from 1966 to 2016 in Helsinki, Finland.Respir Med. 2019; 155: 121-126Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar In 2016, 2.5% of individuals with asthma regarded their symptoms as severe, as compared with 4% in 2010 and 10% in 2001.31Jantunen J. Haahtela T. Salimäki J. Pelkonen A. Mäkelä M. Kauppi P. Astma ja allergia lievenevät Suomessa – apteekkien allergiabarometri 2010-2016 (Asthma and allergy are becoming less severe in Finland – pharmacy barometer surveys 2010 and 2016).Suom Lääkäril. 2018; 73 ([in Finnish; abstract in English]): 367-371Google Scholar In the 2000s, annual asthma deaths decreased from 117 to 74, and in the population younger than 60 years, an average of 7 asthma deaths per year were recorded. In Finnish children younger than 20 years, the rate of hospital admission due to asthma was 51% less in 2014 than in 2005, whereas the rate remained stable in Sweden.32Kivistö J.E. Protudjet J.L.P. Karjalainen J. Bergström A. Korppi M. Trends in paediatric asthma hospitalisations - differences between neighbouring countries.Thorax. 2018; 73: 185-187Crossref PubMed Scopus (9) Google Scholar During the period from 1999 to 2011, the rates of hospital admission due to allergic reactions among children younger than 20 years in Finland were compared with those in Sweden.33Kivistö J.E. Protudjer J.L. Karjalainen J. Wickman M. Bergström A. Mattila V.M. Hospitalizations due to allergic reactions in Finnish and Swedish children during 1999-2011.Allergy. 2016; 71: 677-683Crossref PubMed Scopus (32) Google Scholar The rates doubled in Finland but almost tripled in Sweden. In 17 years (1996-2013), anaphlyaxis caused 56 deaths in Finnish adults and no deaths in children.34Kivistö J.E. Dunder T. Protudjer J.L.P. Karjalainen J. Huhtala H. Mäkelä M.J. Adult but no pediatric anaphylaxis-related deaths in the Finnish population from 1996 to 2013.J Allergy Clin Immunol. 2016; 138: 630-631Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar From 2000 to 2011, the direct health care costs caused by allergic diseases and asthma, together with costs of disability rendering individuals unable to work, decreased by 9%.26Jantunen J. Kauppi P. Linna M. Martikainen J. Mäkelä M. Pelkonen A. et al.Astman ja allergian kustannukset ovat suuret mutta laskussa [Asthma and allergy costs in Finland are high but decreasing].Finnish Medical Journal. 2014; 69 ([in Finnish; abstract in English]): 641-646Google Scholar A comparison of the years 2007 and 2018 and use of comparative data revealed that these costs fell by 30% (approximately €200 million) (Fig 1, D). In 2018, the total cost of allergic diseases and asthma in Finland ranged from €1.5 to €1.8 billion (Fig 2). A simple example of combating medicalization was the policy regarding milk allergy in preschool children, who used to be entitled to reimbursement for hypoallergenic milk products if a doctor had documented the need. The criteria were revisited in 2006. After that, use of special formulas was reimbursed only if the diagnosis was based on milk challenge performed at a pediatric outpatient clinic. Following revision of the instructions, the number of children needing the hypoallergenic products decreased by 70% and the cost decreased by €4.5 million (according to a comparison of the years 2007 and 2018). All citizens were included in the program for changing the strategy from avoidance to tolerance, endorsing health instead of allergy, and prioritizing severe clinical manifestations.23Haahtela T. Valovirta E. Bousquet J. Mäkelä M. the Allergy Programme Steering GroupThe Finnish Allergy Programme 2008-2018 works.Eur Repir J. 2017; 49: 1-6Crossref Scopus (36) Google Scholar,35Haahtela T. Valovirta E. Saarinen K. Jantunen J. Kauppi P. Pelkonen A. et al.Kansallinen allergiaohjelma muutti asenteita ja vähensi sairastavuutta [Finnish nationwide allergy programme 2008-2018 changed attitudes and reduced morbidity].Finnish Medical Journal. 2020; 75 ([in Finnish; abstract in English]): 1760-1769Google Scholar A large-scale educational effort—both for health professionals and for the lay public—was carried out. Finland has a functional public health care sector; however, the private sector, especially for children and working-age people, covers almost half of all outpatient visits. Thus, our results are applicable to most countries with developed health care.