Many GPs will look after patients who are members of the Roma community. As a socio-economically deprived group, this community experiences many difficulties. Poor living conditions, low literacy levels and communication issues contribute to their poor health and to difficulties in accessing healthcare. This article gives a synopsis of what is known about the health of the Roma community in Europe and in Ireland, and outlines some of the services that are available to them.

The Roma community

The Roma community are a people originally from northern India who migrated to Europe between the 9th and 15th centuries. Although initially welcomed, they were subsequently enslaved, expelled from various countries, and suffered widespread discrimination throughout history. More than half a million Roma were exterminated in Nazi concentration camps during the Second World War.^1,2

The Roma are now the largest ethnic minority in Europe. The true number of Roma in Europe is difficult to estimate but numbers range from seven to 15 million.¹ The Roma have evolved into diverse groups with a common ancestry but varying backgrounds and dialects. While some Roma have assimilated into the culture of their adopted countries, many have maintained their traditional itinerant lifestyle and tribal organisation.³

Since the early 1990s, increasing numbers have come to Ireland and made their home here. Up to 90% of the Roma in Ireland are from Romania, with smaller numbers from the Czech Republic, Slovakia, Bulgaria and Poland. Information regarding the number of Roma living in Ireland is lacking. Estimates of the number of Roma in Ireland vary from 3,000 to 7,000, however the true number is unknown.^1,3

Health status of the Roma community in Europe

Very little is known about the health status of the Roma community in Ireland. However, some information exists about the health of the Roma population in Europe.

A recent report based on data from seven EU countries found that the population pyramid of the Roma was considerably different to that of the non-Roma population. The pyramid was found to have a broad base, meaning that a large percentage of the population were children, and a narrow apex from age 35. This means that there is a high birth rate in the population but also a high mortality rate at a relatively young age with few people surviving into old age.⁴ This is similar to the population pyramid seen in many low-income countries, eg. countries in sub-Saharan Africa. In contrast, the population pyramid for high-income countries has a narrow base, indicating a lower birth rate and is broader near the apex, meaning that many people are surviving into old age.⁴ In several European countries, Roma have a life expectancy that is 10 to 15 years shorter than their non-Roma counterparts.⁵ Infant mortality rates in the Roma are also high; in Slovakia, Hungary and the Czech Republic infant mortality rates in Roma are twice those for the general population, and three times those of the general population in Italy.⁵

Infectious diseases

Studies have demonstrated higher rates of infectious diseases in Roma populations in several European countries, when compared to non-Roma populations. This has been shown to be the case in relation to tuberculosis, hepatitis A and B and hepatitis E.^6,7 Poor living conditions, as well as low immunisation rates, are likely to contribute to the high levels of infectious diseases seen in this population. In Spain, one study found that 82% of Roma children were hepatitis A antibody positive compared with 9.3% of non-Roma Spanish children.⁷

In recent years there have outbreaks of vaccine-preventable diseases in Roma communities in Europe, including several measles outbreaks and indeed wild poliomyelitis in a Roma community in Bulgaria.^8,9

Chronic diseases

Little is known about the prevalence of chronic diseases and their related risk factors in the Roma population. Studies suggest that the Roma have high rates of cardiovascular disease and its risk factors. In Slovakia, higher levels of hypertension and obesity were found in the Roma compared with the majority population,¹⁰ while in Croatia, smoking levels exceeded 70% in the Roma community, a considerably higher level than seen in the non-Roma population.¹¹ Lower uptake of preventative healthcare such as mammography and cervical smears were found among Roma women when compared with the general population in several European countries.⁴

Self-reported health 

Self-rated health has been shown to be a strong indicator of overall health and wellbeing. Several studies, including those in Hungary and Serbia, have demonstrated high levels of poor self-reported health in the Roma when compared with the general population.^12,13

Accessing healthcare

Accessing healthcare for the Roma is difficult and there are widespread reports of discrimination.¹⁴ A survey in Hungary found that direct discrimination was a major barrier for the Roma, with up to 44% of respondents reporting direct discrimination by GPs, while refusals by doctors to accept Roma as patients was also common.⁶ This is despite the fact that under EU law, racial and ethnic discrimination in the provision of healthcare is prohibited.² Financial barriers to accessing healthcare exist, and in addition there is a requirement in many countries to have various identity papers and to fulfil employment or unemployment criteria in order to access free healthcare.¹⁵ Cultural barriers also exist, most notably the Roma’s belief in traditional cures and their beliefs surrounding the purity of different parts of the body.³

The Roma in Ireland 

Little is known about the health of the Roma in Ireland or the barriers that they face in accessing healthcare. It is likely that just like in other European countries, infant mortality rate, life expectancy, health and access to healthcare is significantly worse for members of the Roma community than for the general population. Internationally, it is known that ethnic minorities suffer poorer health than the majority population in a country. The All Ireland Traveller Health Study demonstrated this with regard to Irish Travellers in Ireland.¹⁶

The legal status of Roma in Ireland and their entitlements to social welfare benefits vary widely. Those who came to Ireland in the early 2000s came as asylum seekers, and therefore were entitled to free medical care while their application was being processed. Some were subsequently granted refugee status. In 2005, the Department of Justice in Ireland deemed Romania a safe country. As a consequence, asylum seekers from Romania had their applications rapidly assessed and many were returned to their country of origin. Others have leave to remain in Ireland due to having an Irish-born child, born before January 1, 2005 or have been granted Irish citizenship through naturalisation.^3,17

Since 2013, all EU citizens including those from Romania and Bulgaria have free access to the labour market. The habitual residency requirements for social welfare and other benefits for EU citizens means, however, that Roma from any EU countries are not entitled to certain social welfare benefits unless they have been in employment in Ireland or habitually resident in the country for 6-12 months.¹⁸

With regard to healthcare entitlements, in common with all other individuals ordinarily resident in Ireland, Roma people are entitled to a medical card if they fulfil eligibility criteria. However, documentation such as proof of employment or proof of residency at an address is required.¹⁹ This may present a barrier to accessing healthcare, as has been shown in other European countries, particularly for the most vulnerable that may be living on the margins, in temporary accommodation or with family and friends.⁷

In addition, poor literacy and language difficulties mean that Roma people may be misinformed about their entitlement to benefits including healthcare, or have difficulties in applying for and renewing medical cards. Cultural differences as well as literacy and language barriers may mean that some Roma may not make or keep appointments, or follow up with care.^3,20 Discrimination and prejudice are also likely to play a role in limiting access to healthcare for the Roma in Ireland. 

Services for the Roma community

As well as accessing mainstream primary care services, many members of the Roma community also attend primary care clinics for people who are homeless, such as The Capuchin Centre in north Dublin city centre, which has a Roma translator available on site. 

More recently, a primary care service, funded by the HSE specifically for members of the Roma community, opened in the grounds of Tallaght Hospital. This service has on-site translators and cultural facilitators.

Many voluntary organisations also offer services to the Roma community. Pavee Point, a voluntary organisation for human rights for Irish Travellers and Roma is a source of information on Roma culture, human rights and the wider implications of government and EU policy. Crosscare, St Vincent de Paul and Pavee point have produced a joint information leaflet for the Roma community in Romanian called Romale Aven Cate: Roma Included Too, which gives contact details of advice and other services for the Roma community in Ireland, although these are almost exclusively located in Dublin. This is available to download at: www.paveepoint.ie/tempsite/what-we-do/programmes/roma/

References

1. Council of Europe. Roma and Travellers [cited 2012]. Available from: www.coe.int/t/dg3/romatravellers/default_en.asp
2. Rights CfH. Human Rights of Roma and Travellers in Europe. Council of Europe, 2012
3. Pavee Point Travellers Centre. Roma [cited 2012]. Available from: http://paveepoint.ie/about-2/structures/roma/understanding-roma-culture/
4. Fundación Secretariado Gitano Health Area. Health and the Roma Community, analysis of the situation in EuropeBulgaria, Czech Republic, Greece, Portugal, Romania, Slovakia, Spain. 2009
5. Sepkowitz KA. Health of the world’s Roma population. Lancet. 2006; 367(9524): 1707-8
6. Open Society Institute. Public Health Program. Left Out:Roma and Access to Health Care in Eastern and South Eastern Europe. 2007
7. Hajoff S, McKee M. The health of Roma people:a reviewof the published literature. Journal of Epidemiology and Community Health. 2000; 54(11): 864-9
8. Lopalco PL, Martin R. Measles still spreads in Europe: Who is responsible for the failure to vaccinate? Stockholm: ECDC; 2010 [cited 2012 21/05/2012]. Available from: http://www.eurosurveillance.org/images/dynamic/EE/V15N17/art19557.pdf
9. Kojouharova M, Zuber PL, Gyurova S, et al. Importation and circulation of poliovirus in Bulgaria in 2001. Bull World Health Organ. 2003; 81(7): 476-81
10. Vozarova de Courten B, de Courten M, Hanson RL, et al. Higher prevalence of type 2 diabetes, metabolic syndrome and cardiovascular diseases in gypsies than in non-gypsies in Slovakia. Diabetes Res Clin Pract. 2003; 62(2): 95-103
11. Zelijko H, Skaric-Juric T, Narancic NS, et al. Traditional CVD risk factors and socio-economic deprivation in Roma minority population of Croatia. College of Anthropology. 2008; 32(3): 667-76
12. Kosa K, Lenart B, Adany R. Health status of the roma population in Hungary]. Orv Hetil. 2002; 143(43): 2419-26
13. Janevic T, Jankovic J, Bradley E. Socioeconomic position, gender, and inequalities in self-rated health between Roma and non-Roma in Serbia. Int J Public Health. 2012; 57(1): 49-55
14. Foldes ME, Covaci A. Research on Roma health and access to healthcare: state of the art and future challenges. Int J Public Health. 2012; 57(1): 37-9
15. Danova-Russinova S. Ambulance Not on the Way: The Disgrace of Health Care for Roma in Europe. Budapest: European Roma Rights Center; 2006
16. All Ireland Traveller Health Study Team. Our Geels: All Ireland Traveller Health Study:Summary of findings. School of Public Health,Physiotherapy and Population Science,University College Dublin.: 2010
17. Refugee Information Service. Rights and Entitlements  [cited 2012 17/05/2012]. Available from: http://www.ris.ie/detail.php?category_id=8
18. Pavee Point Travellers Centre. Position Paper.Impact of the Habitual Residence Condition on Travellers and Roma. 2011
19. Citizens Information Centre. Entitlement to Health Services  [cited 2012]. Available from: http://www.citizensinformation.ie/en/
20. Lesovitch L. Roma Educational Needs in Ireland. Context and Challenges. Dublin: City of Dublin VEC in association with Pavee Point Travellers Centre and the Roma Support Group, 2005