ture in the future. While some of these potential problems have already been highlighted,8 the weakening economy is causing a sharp decline in living standards, mass unemployment, and continued dependence on heavily polluting industries. There is no sign that public health problems will decrease. In this environment the need for public health skills has never been greater. We thank Dr Theo Miltenburg of the Institute of Applied Social Sciences, Nijmegen, Netherlands; all the staff at Kaunas Medical Academy who helped us gather information and ideas; and in particular Dr Zilvinas Padaiga and Professor Grabauskas for organising the trip. We also thank Dr Caroline Collier of the Department of Health for sponsoring the visit, North West Thames Regional Health Authority for its support, and Drs M McKee and N Black for their comments on previous drafts of the paper.

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