Letter from Latvia: surviving surveillance.

During my stay in Riga (one of the oldest cities in Europe' and capital of a country about the same size as the Republic of Ireland with a population of 2 5 million) I spoke at the Ministry ofHealth and at the First Children's Hospital. I was privileged to have Professor I Lazovskis (Juris's father and professor of internal medicine at the Latvian Medical Academy) as my interpreter. As we sat in the park near the opera house discussing the lectures, Professor Lazovskis commented that if he had been speaking English like this a year ago a KGB officer would probably have appeared to ask for an explanation. It is hard to comprehend the effect of this continual surveillance; until recently the BMJ arrived in Latvia with articles such as those by Ryan on Soviet health care2 removed. In one talk I presented some data about inequalities of health among children in the United Kingdom, illustrated by death rates by occupational class. The audience were unwilling to believe the data; it was too reminiscent of propaganda of the Breznev era, rejection of which has led to a belief that everyone in the West is very well off. Comparable data on child health in the Soviet Union are neither readily available nor reliable, at least in part because of the practice of setting "central planning norms" for medical' activities, and then applying pressure locally for them to be met. This can result in a divergence between actual and reported activity. castle ofBaron Von Wulf(now a secondary school) still brooding over its moat and outbuildings. These now form part of the collective farm, which with the squat local Soviet headquarters, cafe-restaurant, public library, factories for bread and cheese, and queues for these commodities in the shops make up the heart of the village. The polyclinic is staffed by Dr Lazovskis, a paediatrician, a gynaecologis-t, midwife, two nurses, a dentist and dental technician, a laboratory technician, a pharmacist and eight assistants, one notes clerk, washers up, oven lighters, and a chauffeur. Dr Lazovskis tried initially to meet the planned preventive targets for the 2200 adults of Cesvaine; 80% were to be screened annually and 200 were to be put on the chronic disease registers and seen four times a year. With the nurse he set up an intricate colour coded agesex and morbidity index with separate registers for chronic disorders. (At risk occupations such as teachers, health workers, library workers, milkmaids, and war veterans are all to be examined two to four times a year.) Every evening the nurse brought the lists up to date. The nurse wrote 5000 letters in one year to try to get the patients to come. Initially, they did come, but the queues were long and the computer returns took months to come back. When they did, a countrywoman might discover that she must visit the neurologist in the town 15 km away for her headaches, see the narcologist for her smoking habit, and consult the gastroenterologist for her dyspepsia. Gamely, she may have tried to consult, only to find that two doctors