The arrival at Dover of groups of Gypsy (Roma)
families from Slovakia seeking asylum in Britain has briefly focused the
attention of the British media on this poorly understood people.(1)
The Roma are one example, albeit a substanial one, of minority communities
throughout Europe whose way of life and health needs are largely ignored
by the majority communities.
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
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
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
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:
3. Brearley M. The Roma/Gypsies
of Europe: a persecuted people. London: Institute for Jewish Policy
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
6. Martinez-Frias M L, Bermejo E.
of congenital anomaly syndromes in a Spanish Gypsy population.
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