Over 5 million Roma people live in the countries of central and eastern Europe. Originally from northeastern India, they began a slow westward migration about 1,000 years ago. By the fifteenth century they were well established in the Balkans, with smaller groups throughout western Europe. At first they were welcomed, claiming papal protection as penitent pilgrims, but the intolerance that accompanied the reformation and the rise of the nation state in the sixteenth century soon led to persecution. In the eighteenth century Austria-Hungary required Roma children over five to be taken from their parents and brought up in non-Roma families. In Romania, Roma people were kept as slaves until the 1860s. Up to 500,000 were exterminated in Nazi camps.

In central and eastern Europe Roma people continue to exist on the margins of society, subject to widespread and often institutionalised racism. Although subject to attempts at forced assimilation by the postwar communist regimes, they were also afforded some protection, but this has largely disappeared in the 1990s, with an increase in racist attacks, often with semiofficial approval.

Against this background, it is unsurprising that health policymakers and researchers have paid little attention to the health needs of Roma people, even though their distinctive way of life suggests these needs may be different from those of the majority population. With estimates suggesting that they account for over 5% of the population in Bulgaria, Hungary, Romania, and Slovakia, they are a far from insignificant minority. This failure to address their needs becomes apparent when a Medline search on the term "Gypsy" yields rather more papers on the gypsy variant of the Drosophila fruit fly than on the health of the Roma people.

Even the numbers of Roma people are uncertain because of their reluctance to identify themselves and enforced assimilation. In several countries their distinct national identity was recognised in censuses for the first time in the 1990s. The few studies that exist suggest that their life expectancy is up to ten years less than that of their non-Roma neighbours and that infant mortality is up to four times higher.(2) The much higher levels of poverty, lack of education, overcrowding, and unemployment suffered by the Roma people probably play an important part, but we know little about their specific patterns of disease and how these differ from those of other groups.(3)

What evidence exists is largely from other parts of the world and is fragmentary. A study in Spain reported a nine times greater prevalence of antibodies to hepatitis A in Roma children than in the non-Roma population.(4) Another Spanish study reported that Roma children were at particularly high risk of lead poisoning.(5) Some Roma groups have a high incidence of inherited congenital malformations.(6) Some small scale research has also been conducted in the Czech Republic and Hungary but most of it is not widely known.

There is also a lack of knowledge about access to health services and how to provide them appropriately. Ethnographic research among American Roma people has identified a strongly held set of health related beliefs in which some diseases are seen as Roma, and thus treated by traditional healers, and others as due to contact with the outside world, requiring the services of the formal healthcare system.(7) Relations with the majority population are governed by a series of rules about what is pure or impure. There are also a range of specific rituals dealing with birth, death, and caring for the ill. These can lead Roma people to accept some aspects of care and reject others, behaviour that is often seen as irresponsible for not fitting in with the norms of the majority.(8)

In central and eastern Europe the principle that public health practitioners should explicitly address the health needs of minorities is not well established. Unfortunately, those in western Europe are not exempt from such criticism. Although much research now exists on some groups, such as south Asians in the United Kingdom, the health needs of many other groups have received little attention; in this sense the Roma people are only one group among several neglected communities, although their situation is particularly difficult.(9)

Some groups have been among us for hundreds of years and are now on the wrong side of a national frontier. Others, such as the Turkish guest workers in Germany, are more recent arrivals. The reasons for not addressing their distinct needs vary, with some countries assuming that equality under the law equates to equality of health and others ignoring those who, while contributing to the economy, are not citizens. Some countries are reluctant to pursue research that might stigmatise groups and make their plight worse. This is a particular concern with regard to the Roma people in the present climate. Any research must obviously be handled with sensitivity to the political and historical environment and may be difficult where there is a long legacy of distrust. Nevertheless, at the end of the twentieth century it should no longer be acceptable for European governments to ignore the health needs of significant numbers of their inhabitants.

1. Mills H. No Gypsies please, we're British. Observer 1997; 26 Oct: 19.

2. Braham M. The untouchables: a survey of the Roma people of central and eastern Europe. Geneva: UNHCR, 1993.

3. Brearley M. The Roma/Gypsies of Europe: a persecuted people. London: Institute for Jewish Policy Research, 1996.

4. Cilla G, Perez-Trallero E, Marimon JM, Erdozain S, Gutierrez C. Prevalence of hepatitis A antibody among disadvantaged Gypsy people in northern Spain. Epidemiol Infect 1995;115:157-61.

5. Redondo M J, Guisasola F J. An unknown risk group of lead poisoning: the Gypsy children. Eur J Pediatr 1995;154:197-200.

6. Martinez-Frias M L, Bermejo E. Prevalence of congenital anomaly syndromes in a Spanish Gypsy population. J Med Genet 1992;29:483-6.

7. Fonseca I. Bury Me Standing: the Gypsies and their Journey. London: Chatto and Windus, 1995.

8. Sutherland A. Gypsies and health care. West Med J 1992;157:276-80.

9. Abel-Smith B, Figueras J, Holland W, McKee M, Mossialos E. Choices in health policy: an agenda for the European Union. Luxemburg: Office for Offcial Publications of the European Communities, 1995.