On the chilly evening of January 20, 2001, scattered snowflakes were flying around in the air and cold winds penetrated even warm clothing. The glow of a bonfire outside the parliament building in Riga lit up the faces of a crowd gathering around the flames with warm cups of tea in their hands. What was the silent group doing?

They were commemorating. Celebrating, thinking back and reflecting over memories of what had occurred in just the same place ten years ago, in January 1991.

Although having gradually developed over some years already, the liberation process of the three Baltic countries Estonia, Latvia, and Lithuania had culminated in those not so remote winter days of 1991. Already on August 23, 1989 more than two million people had linked themselves together with their hands and formed an impressive human chain stretching from Tallinn in the north through Riga to Vilnius in the south, demonstrating quite clearly a message to the leaders in Moscow and their local supporters which could not be misunderstood: a firm will and a steadfast readiness to part from the already frail Soviet Union were indeed there.

Readings of political history * Well documented overviews are given by Plakans (1995) and Dreifelds (1996). can give a detailed account of the many dramatic events taking place in the months to come. At that time, however, the importance of the broad perspective and of the tight interdependence between seemingly quite different global political issues should not be underestimated: Iraq had invaded Kuwait on August 2, 1990. The attention of the world and the eyes of media had instantly shifted to what was going on in the Gulf region, leaving more unattended space for changes in politics elsewhere, as e.g. when it came to the Soviet-Baltic relationship.

The liberation process had a serious potential to become dangerous, not least as the somewhat softening politics in Moscow over the preceding years, had met strong domestic opposition by hard-liners. And the Soviets had flexed their muscles in similar situations in the south-east of the Union.

In Latvia, there had even been skirmishes, as Soviet supported local «saviours of the empire» had attempted to stage an uproar and storm the Latvian Supreme Court building in Riga in May 1990. Then the so called «Black Berets», a military unit representing the Latvian Communist Party, carried out several armed actions with support from the East during the autumn of 1990, until the situation became particularly tense in January 1991. The Latvian Press Building had been taken over by the Black Berets on January 2, 1991, causing very obvious information problems.

At the same time the liberation process in neighbouring Lithuania culminated in clashes with Soviet armed forces on January 11–13, 1991, in Vilnius, leaving 14 killed and more than 600 injured. And on January 20, 1991, the Black Berets tried to occupy the Ministry of the Interior in Latvia, killing five and wounding several people. However, Soviet troops did not intervene, following orders from highest levels in Moscow. Boris Yeltsin had signed a treaty accepting Baltic sovereignty.

In those very nervous January days of 1991, Latvians had set up barricades and lit bonfires in the city centre of Riga to defend official buildings perceived as threatened. Of course, in the light of history this became more of a demonstration of political will than of military force. If a large scale attack had been set in, in military terms even desperate local resistance would probably have been in vain. In any case, it was this demarcation of freedom which was celebrated by the people around the bonfire in Old Riga on January 20, 2001, ten years after the killings.

The situation in January 1991 calmed down. However, the state of alarm persisted during the following spring and summer, in part due to the unsuccessful hard-liner coup in Moscow on August 19, 1991. In Latvia the political turmoil led to an immediate takeover of important buildings in Riga by the Red Army on August 20, 1991. But Latvian authorities perused the new and unclear situation to declare total independence for Latvia on August 21, 1991.

The coup in Moscow collapsed almost immediately. In Riga Soviet troops withdrew from the occupied buildings. Already on August 24, 1991, Russia officially recognized Latvian independence. Recognitions by other countries followed suit, and Latvia became member of the United Nations on September 17, 1991. The exit of Latvia from the Soviet Union was now a fact.

The Latvians found themselves living in a new society. As the country had been under foreign rule for 51 years, only a minority of the living population had personal memories from the previous independence period which lasted from 1918 to 1940. 51 years is a long time – even if it was possible to lean on an old constitution and on an administrative system from the past, in reality it was necessary to start anew.

Quite anew.

A complicated time was ahead, both for the state leaders and for the population. Also for the individual citizens most things had to start from scratch.

It is not the intention of this book to review the political or social history of Latvia. The literature on these topics is abundant* See e.g. Lieven 1994 or Nørgaard et al. 1999.. The intention is to give an introduction into the prevailing health conditions in Latvia in the years that followed. We also want to discuss the conflict of values emerging when a new and widened concept of health meets the prospects and pitfalls of new welfare and quality of life standards. Latvia had entered a liberal market society, where everyone was more on his own than anyone had been used to.

Health depends not only on living conditions, nutrition, housing, health care and other factors more or less directly connected to physical and mental health, but also on a series of intervening issues. These range from genetics over attitudes towards health and health factors, the physical and social environment at large, and not least the attitudes towards health and the attention to health issues. The authors want to shed light on some of these factors, not to explore them in the detail they definitively deserve, but more to pay attention to them and point to them from a general community medicine perspective.

The transition process confronting the Latvian leadership could seem overwhelmingly difficult. And what were their objectives? In the first place an administrative system had to be built up which was really based on independence, without the former ties to Moscow. More than a generation of Latvians had grown up and lived under an administration which now had to be changed; no surprise that opinions were abundant. And the population was the same after 1991, around half Latvians, around half Russians.

When it came to the question of loyalty to the administrators and the loyalty and readiness towards changes among the administrators themselves, especially on the lower levels, an important fact should be considered: Provided that necessary resources and other prerequisites were at hand, a centralized Soviet system, aside from its obvious unintentional fallibility in many ways, might have worked under the new conditions, maintaining jobs and routines. However, facing the fact that the times of low cost manpower of the Soviet era were now more or less over, and that unemployment was looming, might have put the brakes on the enthusiasm for change as well.

Soviet Latvia had a well educated population. However, the heavy ideological contents of schooling and training, internalised in people’s minds since childhood by a larger part of the population, now was suddenly devaluated and seemed useless. Liberty was fine, but what about the changes which were needed? What was freedom like? The understanding and appreciation of democratic principles are virtues which cannot be taken for granted, even if the Latvians nurtured persistent dreams of the interwar democratic period.

Riga freedom monument, December 2002.

For all to see, the turning point of 1991 pointed to new prospects and possibilities for a better life, but also to misery and difficulties for many who had only few means to withstand or abilities to adjust: Pensioners and the unemployed, professionals in jobs related to the former political ideology.

Expensive western cars which soon began to cruise the highways, set new standards for what sort of vehicle one should strive for, and made the previously precious Ladas, Moskvichs and Volgas look rather old-fashioned. The streets became a constant means of showing off which proved that new class differences had developed. The substantial number of new political parties and ever shifting top politicians indicated that implementation of democracy still was in need of maturation. When the euphoria of independence had waned, reflections came up: In the change from a very modest, yet stable society into this turmoil of freedom, albeit with potential for prosperity, how much am I willing to sacrifice and how far do I accept to go?

Secondly, it was obvious to everyone that living conditions had to become better, even if Latvia had been one of the best off among the Soviet republics, holding higher standards than in many other places of the Union. In spite of this prime position, standards were definitely lower than in the West, and they were different. Within which framework, with which aims and endpoints and at what pace should changes occur? Even if feasible in a short perspective: Would it be enough and satisfactory in the long run only to secure prosperity, standards and lifestyle matching what could now be watched on western TVchannels? These were rather haphazard and confusing expectations for a new well-being.

In these matters the larger picture of Latvia as a European nation had to be considered by the responsible politicians. Soon the objective shifted from aiming at a mere modernisation and upgrading of the new and independent society – a task difficult enough. It became clear to many in the Latvian leadership, that the way to a stable and secure future would be to apply for membership in the European Union. In this case, however, an application would require fulfilling a series of demands set by the Union, influencing society down to details of daily life. The application procedure would set the agenda for the modernisation. Therefore, the reorganisation process also became a process of adaptation, where the overruling principles of aiming at EU membership were not unanimously shared by the population. An important fact to be remembered is that a large part of the Latvian population were ethnic Russians with traditional ties to the East. However, preparations were made for an entry into the EU, and changes in society were carried through accordingly. The timetable and schedule had been set by international politics, not by the ambiguous local voters.

The crucial point in the application process was the referendum day when the population had to vote yes or no to the final results of the EU negotiations – yes or no to entering the EU. The day was Saturday, September 20, 2003. The excitement was tense: Discussions pro et contra had come to a climax, emotions had been stirred up. Arguments and issues, relevant or not had been taken in. Even mere rumours had caused nervous attention, confusing the minds and making the outcome vote unpredictable. Examples of these rumours include: Widespread impressions were around that within the EU coarse salt would not be available. Or: When in the EU the Riga Central Market, providing food and necessities for a large part of the Riga population, would have to be closed on Sundays. However, in many heads which had been kept cool, attitudes were prevailing that the independence of Latvia, as a small and vulnerable country, would benefit in the long run from joining in with other European countries.

For the time being Latvia had a weak economy and many problems remained to be solved, a situation different from those other non-EU countries in Europe which were on top of the prosperity list, like Norway and Switzerland. Paradoxically enough, the Latvian politicians felt that their wish and sincere intention to maintain independence simply was dependent on giving away a bit of it. It would be in the interest of all to pursue a unionist line, was the opinion among the promoters of EU membership.

Myself, I experienced the tension of September 20, 2003 on board a railway train rolling through the deep forests of North-West Russia. My fellow passenger in the compartment was my Latvian friend and co-author of this book, Guntis Kilkuts. He looked nervously at the display of his cellular phone every time the train passed through a village or a township where he could hope for network coverage: Would there pop up a message from his friends back home informing about the referendum result? At last the message came: Around two thirds of the Latvians had voted «yes». He relaxed.

However, the adaptation to EU standards which had been going on for years now, had influenced daily life of the Latvians in almost all fields, including health, conditions for health and for health care.

Therefore, the time window of history to which the contents of this book belong, starts with the crowds defending their freedom prospects in the January days of 1991, which were commemorated around the bonfire in Old Riga on January 20, 2001. And it ends with the crowds celebrating the entrance into the European Union in Old Riga on May 1, 2004.

Joining the EU: Heavy celebration in the night between April 30 and May 1, 2004!

Øivind Larsen