This document discusses tuberculosis (TB) in Roma communities in Europe. It notes that the Roma population of around 10 million people experiences significant health inequities and health needs. Several studies presented found high rates of TB, HIV/AIDS, and other diseases in Roma communities. Socioeconomic factors like poverty, low education levels, unemployment, and overcrowded living conditions significantly impact the health of Roma people. While socioeconomic status explains some health differences, cultural factors also influence health behaviors and outcomes for Roma populations. The document calls for public health efforts to address both socioeconomic and cultural determinants to improve health in Roma communities across Europe.

1. Tuberculosis in Rroma communities
in Europe
Traian Mihaescu

2. The Rroma population represents an
ethnic group of 10 million
individuals living in almost all
European countries:
“the most populous marginalised
community in Europe having some
of the greatest health needs”
Parekh N, Rose T. Cent Eur J Public Health 2011

3. The Economist, 2001

4. Linguistic, anthropological, historical and genetic
evidences point out India* as the origin of the
Rroma populations, which may have left the
continent approximately between the 5th–10th
centuries . After leaving India, the Rroma
migration route passed through Persia, Armenia,
Greece and the Balkans.
*the Punjab state, in North-western India
Mendizabal I et al. PLoS One. 2011

6. In UK and Ireland
Gypsies and Travellers report poorer health on
standardised measures than comparable groups
of residents from socially deprived inner city
areas, other ethnic minorities and rural
residents.
Poorer health status was reported in relation to long-term
illness, health problems that limit daily activities or work,
health-related quality of life, chest pain, respiratory
problems, arthritis, miscarriage and premature death of
offspring.
Parry G et al. J Epidemiol Community Health 2007

7. Incidence of TB, AIDS, imprisonment and
injecting drug use in a Roma population.
Barcelona (1985–2008)
Rate/100 000pyf (95% CI) Global
TB 90.9 (68.5–113.2)
AIDS 104.1 (80.1–128.0)
Imprisonment 642.0 (579.7–704.3)
IDU 239.8 (203.0–276.6)
Casals M et al. Eur J Publ Health 2011

8. In 126 gypsy patients, aged over 15, registered
with TB in two districts of Bucharest, Romania
• 83% of bacteriological confirmed cases were
smear positive
• 48% succes rate
• 66.7% associated diseases/comorbidities
Dediu I et al. Pneumologia 2000

9. A prospective study of detection of TB infection
in the rroma community fom the west of
Romania (July 2009-December 2010):
• 1417 persons surveyed
• 700 (49,40%) with positive TST
• 73.42% no BCG scar
• 51.43% positive TST - men
• 71,20% had recently tb contact
Nini G et al. ERS Congress 2011

10. Active TB screening in Rroma population,
Belgrade, Serbia:
• 407 registered adults
• 167 (41%) presented and id chest X-ray
• 8 subjects suspects – no TB case M-/C-
• 224 children
• 202 examined
• 16 TST positive – none diagnosed with TB
Curcic RV et al. ERS Congress 2005

11. Active TB screening in Rroma population,
Vojvodina, Serbia:
• 3958 registered adults
• 870(22%) with suspect chest X-ray
• 7 active cases confirmed (176.9/100000)
Pavlovic S et al. ERS Congress 2005

12. Tuberculosis in a gypsy community (rural,
Romania) has an unpredictible course, primary
tuberculosis is prevalent, and the illness
develops in isolated foci requiring targeted and
sustained surveillance.
Ionita M et al. ERS Congress 2001

13. Published research on the health needs of the Roma
population is sparse!
Hajioff S . J Epidemiol Community Health 2000
A limitation .. which exists in all studies about the
Rroma population, is that follow-up is hindered by
the fact that subject information is found under
different names, shared names and many do not
appear in the registers.
Casals M. Eur J Publ Health 2011
Defining the Rroma population is quite difficult.
Idzerda L.BMC International Health and Human Rights 2011

14. “The common trait of the Gypsies, one that gives
them identity, is a way of life different from that
of other ethnic communities, and most of all a
different strategy of life that has survived to this
day, even if in modern shapes.”
Achim V. The Gypsies in the histoy of Romania, Ed
Enciclopedica, 1998

15. “Family was found to be an important factor influencing the
survival rates..”
Casals M et al. Eur J Public Health 2011

16. The absence of data and comprehensive efforts addressing TB in the
Rroma community is striking.
Schaaf M. Open Society Institute 2007

17. • real numbers –
– migration,
– ethnicity denial,
– uptodate identification papers.
• socio economic status
• education level
• unemployment
• overcrowding

18. Levels of CO and CO2 were higher in winter in both
countries as compared to summer. The limit value of
10 mg/m3 CO was exceeded in a few cases in both
countries. In general, levels of CO, CO2 and PM were
higher in Romania. Further environmental and
behavioural hazards such as indoor smoking, pets
inside or lack of ventilation were found. The reported
self-perceived quality of the indoor environment was
poor in many aspects.
Cent Eur J Public Health. 2012 Sep;20(3):199-207. Assessment of the
indoor environment and implications for health in Roma villages in
Slovakia and Romania. Majdan M, Coman A, Gallová E, Duricová
J, Kállayová D, Kvaková M, Bosák L.

19. Roma scored poorly compared to non-Roma in
psychological well-being, vital exhaustion and
HRQL (p ≤ 0.001); however, these differences
could be to a substantial extent explained by
SES. With regard to personality traits, ethnicity
and SES played a less significant role.
Skodova Z, van Dijk JP, Nagyova I, Rosenberger J, Ondusova D,
Studencan M, et al. Psychosocial factors of coronary heart
disease and quality of life among Roma coronary patients: a
study matched by socioeconomic position. Int J Public
Health. 2010 Oct;55(5):373–380.

20. CONCLUSIONS:
The adverse quality of life among Roma coronary
patients may warrant additional care, which
should target their low SES but also other factors
related to their ethnic background, such as
culture and living conditions.
Skodova Z, van Dijk JP, Nagyova I, Rosenberger J, Ondusova D, Studencan
M, et al. Psychosocial factors of coronary heart disease and quality of
life among Roma coronary patients: a study matched by socioeconomic
position. Int J Public Health. 2010 Oct;55(5):373–380.

21. J Epidemiol Community Health. 2009
Jun;63(6):455-60. doi:
10.1136/jech.2008.079715. Does
socioeconomic status fully mediate the effect
of ethnicity on the health of Roma people in
Hungary? Vokó Z, Csépe P, Németh R, Kósa
K, Kósa Z, Széles G, Adány R.

22. RESULTS:
The health status of people living
in Roma settlements was poorer than that of
the general population (odds ratio of severe
functional limitation after adjustment for age
and gender 1.8 (95% confidence interval 1.4 to
2.3)). The difference in self-reported health
and in functionality was fully explained by the
socioeconomic status.

23. RESULTS:
. The less healthy behaviours of people living
in Roma settlements was also related very
strongly to their socioeconomic status, but
remained significantly different from the
general population when differences in the
socioeconomic status were taken into
account, (eg odds ratio of daily smoking 1.6
(95% confidence interval 1.3 to 2.0) after
adjustment for age, gender, education, income
and employment).

24. CONCLUSION:
Socioeconomic status is a strong determinant of
health of people living in Roma settlements in
Hungary. It fully explains their worse health
status but only partially determines their less
healthy behaviours.

25. CONCLUSION:
Efforts to improve the health
of Roma people should include a focus on
socioeconomic status, but it is important to
note that cultural differences must be taken
into account in developing public health
interventions.

26. Int J Public Health. 2009;54(4):274-82. doi:
10.1007/s00038-009-7108-7.
Socioeconomic indicators and ethnicity as
determinants of regional mortality rates in
Slovakia.
Rosicova K, Geckova AM, van Dijk JP, Rosic
M, Zezula I, Groothoff JW.

27. OBJECTIVES:
Regional differences in mortality might reflect socioeconomic and
ethnic differences between regions. The present study examines
the relationship between education, unemployment,
income, Roma population and regional mortality in the Slovak
Republic.
METHODS:
Separately for males and females, data on standardised mortality in
the Slovak population aged 20-64 years in the year 2002 were
calculated for each of the 79 districts. Similarly the proportions of
respondents with tertiary education, unemployed
status, Roma ethnicity and income data were calculated per district.
A linear regression model was used to analyse the data.

28. RESULTS:
Socioeconomic differences in regional mortality were found
among males, but not among females. While education and
unemployment rate significantly contributed to mortality
differences between regions, income and the proportion
of Roma population did not. The model explained 32.9% of
the variance in standardised mortality rate among districts
for males and 7.6% for females.
CONCLUSION:
Low education and high unemployment rate seems to be an
indicator of regions with high mortality of male and
therefore should be targeted by policy measures aimed at
decreasing mortality in productive age.

29. Potential health related cultural characteristics
• past oriented people
• guided by belief
• time of relative value
– punctuality is not valued (not necessarily meant as
an offense)
– belief in predestination is common (why bother,
why plan, whatever will be will be)

30. Potential health related cultural characteristics
• tabu subjects (usualy sexual matters)
• group oriented people:
– loyality to family is paramount,
– respect to elders,
– sometimes ostility towards the outsiders – gadje
are unclean as they do not follow the rules of
separating the halves of the body.

31. Potential health related cultural characteristics
• schooling may be precarious – cultural
background places little value on gadje culture
– age of ten may be a threshold in following
school – ability to follow complex therapeutic
regimens is reduced.
• ierarchic society – age may matter in health
decisions, elder oriented society

32. Potential health related cultural characteristics
• health and disease beliefs
– healthy as long as autonomy is maintained – late
to seek medical advice, improbable to complete
long treatments
– natural/traditional/herbal treatments may be
prefered/taken without medical advice (older
people)

33. Potential health related cultural characteristics
• health and disease beliefs
– spiritual dimension may play a role
• lower half of the body is considered impure,
• curses/evil eye may work,
• asking forgiveness from the dying

34. Potential health related cultural characteristics
• health and disease beliefs
– hygiene is considered important but may have
different conotations
• may avoid medical institutions as they are impure;
• upper body secretions are pure lower body secretions
are unclean;
• baths are less acceptable than showers;
• prepubescent and older women are purer as there is no
menstruation.

35. Potential health related cultural characteristics
• health and disease beliefs
– older physicians are better
– famous physicians are sought
– medication sharing is common
– general anesthesia may not be acceptable

36. Ethnification of poverty means..

37. …postmodern racism!
Flecha R. Harvard Educ Review 2004

38. It is important for public health across Europe that the health
needs of the Rroma are prioritised by governments concerned.
Parekh N, Rose T. Cent Eur J Public Health 2011