Author: Ilona Tomova Roma, Europe’s most numerous minority, have been victims of prejudice, stigmatization and discrimination for centuries. They are especially vulnerable during times of important social transformation and crises.
Mass unemployment and poverty aff ected between two thirds and three fourths of Roma households dur- ing the post-Communism period.
The transition from a planned state economy to a free market was extremely long and painful in Bulgaria. An entire Roma generation was virtually excluded from the mainstream labour market for almost twenty years.
The community’s geographical isolation increased, aff ecting approximately 80% of Roma (in the late 1980’s fewer than 45% of Roma lived in segregated neighbourhoods). Geographical segregation had an adverse eff ect on Roma’s ability to fi nd jobs during times of crisis and especially aff ected the socialization process of young people. Many Roma neighbourhoods turned into ghettoes. Most of the institutions abandoned these mahali and Roma access to administrative, medical and other services became very diffi cult. A large number of young Roma dropped out of school. Ensuing functional illiteracy has hampered labour market integration and led to poverty extending over generations. Serious mass poverty was the plight of at least two thirds of the Bulgarian Roma population until just recently and will probably rise again due to the current global crisis.
All of this has had a negative eff ect on Roma health and their access to medical services.
Access to health services depends on diff erent factors that have cumulative negative eff ect on Roma health.
The quality of medical services depends on the macroeconomic situation and on state policies specifi - cally targeting health. Total per capita expenditure on health is very low in Bulgaria and Romania. This means that Bulgarian and Romanian citizens have more restricted access to quality health services and that the package of health services in these countries is very meagre. Government curtailment of spending on health services has the greatest eff ect on the poor. Bulgaria has the highest share of out-of-pocket expendi- ture on health. Private medicine accounts for two fi fths of the total expenditure on health in Bulgaria and 96.3% of that is paid out-of-pocket. If patients need surgery or long or permanent treatment, the share of out-of-pocket payment may increase signifi cantly. Financial diffi culties are extremely severe for the poorer social classes and are unbearable for more than two thirds of Roma people.
Bulgaria had quite a good physician, dentist, hospital bed and medical centre ratio but due to low salaries, thousands of nurses and midwives left the country and now the nurse:physician ratio is only 1.2:1. This had led to a deterioration of the quality of medical services and adversely aff ects care provided to the most vulnerable groups: i.e. newborns, young children, the elderly, the chronically ill and the disabled. The Roma community has the highest proportion of newborns and young children and their perinatal, neonatal, in- fant and under fi ve morbidity and mortality rates are the highest in the country. The Roma infant mortality rate in 2001-2004 was 25.0 per 1000, while that of ethnic Bulgarians was 9.9. The insuffi cient number of nurses and midwives has an even greater negative eff ect on Roma because of communication diffi culties between physicians and people with lower levels of education.
Another problem that hits Roma harder than the rest of the population is the uneven distribution of physi- cians and medical centre’s. The highest number of patients per physician is found in the regions with a high proportion of Turks and Roma. This means that the people in these regions, especially rural areas, endure
lower quality medical services, spend longer time waiting in physician’s offi ces and travel longer to visit specialists, medical laboratories or hospitals.
More than two thirds of adult Roma have abandoned the legal labour market and many now work at tem- porary, seasonal or informal jobs mainly in the grey economy. This sort of work is often associated with health problems due to lack of insurance. According to the survey Health and Roma Community: Analysis of the Situation in Europe, 26% of adult Roma (18% of the entire population) have no health insurance. As a result, Roma rely more on emergency services, physician’s altruism and on pharmacists’ advice when pur- chasing medicines without a physician’s prescription.
The mortality rate of those who have undergone successful surgery in hospital emergency rooms is very high because of the poor hygienic conditions in many Roma neighbourhoods or because of the lack of medical care when they return home after a short stay in the emergency unit. Those who survive often have chronic health problems or become disabled as a result of lack of proper care, diet and medication.
Insuffi cient paediatric care may also account for part of the high infant mortality rate, especially in isolated rural settlements.
Stiff regulation of pharmacies by the Bulgarian health system, especially the most recent reform of regula- tions governing prescriptions for chronically ill patients, put many pharmacies out of business or prompted them to simply refuse to work with the public health system. The sale of medicines on the grey market increased and these can now be purchased in cosmetic stores or the offi ces of advertising fi rms. There is no health control regarding the storage of medicines or their quality. According to the survey Health and the Roma Community… four fi fths of adult Roma consume medicines without a prescription. If the trend of bankrupt pharmacies and medicines being sold by people without proper training as pharmacists contin- ues, the lives of thousands of Roma will be at great risk.
Another factor hindering Roma access to health services is their lack of confi dence in physicians. Many Roma (especially those with lower educational levels or who are illiterate) are convinced that physicians and nurses are biased against them on ethnic and social grounds. Many of the problems between Roma patients and physicians could be described as communication problems. The majority of physicians and nurses working in Roma neighbourhoods or in settlements where many Roma reside are not prepared to deal with people with a diff erent culture or who are severely impoverished and or who face social exclusion.
Another signifi cant factor contributing to bad health and a high early mortality rate is poor living condi- tions. According to the Bulgarian National Statistical Institute, almost half of the Roma population lacked potable water in their homes in 2001 and were forced to use water from street pipes or wells. Most Roma neighbourhoods have damaged sewerage systems or none at all and this increases the risk of hepatitis and gastrointestinal disease.
Overpopulation in Roma neighbourhoods and homes is the norm. NSI data show that one fi fth of Roma people live in homes where they have less than 4 sq. m. per capita. Another two fi fths have between 4 and 8 sq. m. fl oor space at their disposal. Often more than three generations live under the same roof. Overpopu- lation in Roma neighbourhoods and homes fosters the spread of disease and is also a cause of everyday distress – intimately related to high morbidity.
Local governments fail to look after hygienic conditions in Roma neighbourhoods. In some cases this is the result of narrow unpaved streets but, generally speaking, there are no cleaning or garbage collection services in some parts of settlements. This lack of proper hygiene and overpopulation are the cause of infec- tious disease and epidemics.
A sociological survey conducted in eight large Roma neighbourhoods in city centres in 2007 showed that in most some repairs or enlargement of the sewerage system had taken place during the previous 2-3 years.
The problem is that in half of these cases, engineering or technical mistakes were made and contaminated water fl oods houses, yards and streets. Hundreds of Euros have been wasted and hygienic conditions for many families have deteriorated.
Most municipal authorities have left Roma neighbourhoods and now there is no control over illegal con- struction and use of sidewalks and streets there. In many places streets are blocked by illegal buildings or they are so narrow that cars cannot go down them. Ambulances cannot reach large sections of Roma ghet- toes and physicians are unable to fi nd the homes of their patients.
Roma have suff ered the diffi culties of the transition to a market economy more than anyone. For the major- ity of men who found themselves permanently excluded from the mainstream labour market, their only chance to gain higher social status and self-respect was illegal activity and control over women. Social exclusion has caused Rome to become increasingly closed off into micro-groups in their homes and ghet- toes. This sparked a return and enforcement of the role of conservative pre-modern patriarchal forms of social and cultural life in the Roma community, especially in large Roma ghettoes. The cult of physical male strength and violence, control over women, restricted possibilities for human development, mass inclusion of young people in deviant forms of behaviour – characteristics of all poor urban ghettoes all over the world – spread among Roma. In some marginalized groups the survival of the family is always at the expense of women and children who are exploited or at the expense of long-term goals like obtaining a good educa- tion or qualifi cation or taking good care of one’s health.
The Roma community is the one which marries the earliest in Bulgaria. The Roma fertility rate from 2001- 2004 was 26.7 per thousand in comparison with 6.9 per thousand among ethnic Bulgarians. Bulgaria has Europe’s highest teen-age pregnancy rate and it is highest among Roma women – 10-12 times higher than that of ethnic Bulgarians. Teen-age pregnancy is a risk factor due to the low birth-weight of newborns, higher neonatal, perinatal and infant mortality and morbidity and higher mortality rate for women giving birth. All of these problems have likewise been observed during this sociological survey.
The survey Health and the Roma Community… defi ned the major characteristics and changes in the social status and family life of rural Roma and those of them who live in large towns and cities in 2008:
Roma with stable employment increased in 2007-2008. One third of Roma adults were employed
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in 2008 and received their health insurance through their job. Despite this improvement, the Roma employment rate is still extremely low.
Roma women depend on their work and own incomes much less in comparison with Roma men and
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with ethnic Bulgarian women. Moreover, most employed Roma women work at seasonal or tempo- rary jobs. This type of employment does not provide its employees with social or health insurance thus putting them in a vulnerable position in times of crises or bad weather conditions.
14% of children age 7-15 are early school leavers and 1.1% of them work full time to provide for
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the family.
Roma men hold the main authority positions in the family and play a major role in providing for the
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family (thanks to their own work or through organizing the exploitation of women and children).
Men were characterized as the ‘head of the household’ or the main provider in nine tenths of Roma households.
In 85% of the households young couples and their children live together with the husband’s parents.
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Most young families depend entirely on their parents’ fi nancial support during the fi rst 10 years of their marriage as a result of early marriages and the high level of youth unemployment in the Roma community. Two thirds of Roma children age 0-9 depend on the fi nancial support of their grand- parents rather than their own parents. Only in the 10-15 year old group is the percentage of those who depend on their parents’ incomes equal to those who depend on their grandparents’ incomes.
Dependency on the husband’s parents and on the grandfathers’ fi nancial support perpetuates the patriarchal model and the authority of men and mothers-in-law.
Sons, much more often than daughters, depend on their parents’ fi nancial support and help in rais-
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ing their children.
No less than 18% of Roma live in households where three or more generations live under the same roof.
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There are more grandmothers than grandfathers in the extended Roma family given women’s longer
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life expectancy. They help more in raising the children but their incomes are much lower than those of men. Older women are often chronically sick or disabled and this contributes to the fi nancial dif- fi culties of extended Roma families.
Roma have been suff ering severe and extended exclusion from the labour market and from other main social spheres. They have no political party with the power to protect their economic, social and cultural interests in Bulgaria. Neither do they have access to the social networks engaged in transforming social capital from the former regime into economic capital in the new market society. The only legitimate power resource they possess is that of male dominance over women in the family and in the community as a whole. Women are the main means of exchange and the accumulation of power in Kaldarash, Lovara, Thra- cian tinkers, and among some Muslim Roma groups. The honour and dignity of the pater-familias and all the men in the family depend on the merits and worthiness of their women, especially soon-to-be-wed daughters. That is why control over girls and women’s bodies in most of Roma groups is so strong and brides’ virginity is valued so high. But this exaggerated focus on pre-marital virginity is one of the reasons behind teen-age marriages in traditional Roma sub-groups: if girls marry in their early teens, the risk of casual sexual contact is extremely low. The other very important reason for early marriages is to keep young people in the community and thus “protect” them from the evils of the outside society. Elders go as far as to encourage even the best Roma students to drop out of school early in order to preserve the community.
Total male control over women is considered necessary for a wide array of reasons. Roma boys will only be considered full-fl edged men when they marry and father a child. This accounts for the strong family and group pressure for early marriage and parenthood. All relatives expect the fi rst child to come within the fi rst year after the wedding. A good wife is one who serves her husband by fulfi lling all of his desires and who shoulders a large part of the housekeeping burden from her mother-in-law. Her work and that of her children, or the social benefi ts she receives if she is an unemployed mother, often cover the household’s expenditure for food and other goods. The family’s economic survival is often secured at the expense of women’s (reproductive) health (and sometimes of that of her children as well).
Young women often say they favour modern birth control methods but do not use them because of their husbands. They often blame their mothers-in-law for perpetuating an old-fashioned attitude towards sex and reproductive health.
The Roma community is the youngest one in the country. Two thirds are children and youth – almost twice as many young people as among ethnic Bulgarians. But this does not mean that theirs is the health- iest community.
As a whole, those surveyed assessed their health and that of their relatives positively: more than half of the Roma over 16 assessed their own health as good or very good. According to 70% of them their children’s health is also (very) good as is that of their family members (67% gave positive answers). One third of those surveyed gave ambivalent answers concerning their own health, 12% claiming it was (very) bad. One fourth said the health of their children and/or that of other family members was not very good and 6% declared that their children or other family members were in a bad health.
The most positive self-assessments were given by Roma age 10–44. The decline occurs immediately after age 45. Less than one fourth of Roma above that age assessed their health positively, one half off ering ambivalent answers and 28% claiming their health to be bad. The most frequently declared maladies diag- nosed by physicians were high blood pressure, migraines or headaches, arthritis and rheumatism, asthma, chronic bronchitis, chronic obstructive lung disease, heart diseases, menopause-related problems, allergy, high cholesterol, stomach ulcers and prostate problems.
Very serious problems in Roma neighbourhoods are linked with infectious diseases. The overpopulation of Roma settlements and households makes it more diffi cult to isolate virus carriers and diseases frequently
turn into epidemics. Some cultural peculiarities also contribute to the spread of disease. One of these is the empathy norm and commitment to the sick implying frequent visits, taking care of them and emo- tional support throughout. This norm is compulsory for relatives, friends and even neighbours. Poor diet, everyday distress connected with long-term unemployment, poverty, uncertainty and discrimination all reduce the organism’s resistance to virus and bacteria and contribute to longer duration of diseases and greater complications. Also, nearly four fi fths of Roma complain that they do not have enough money to buy needed medicines, especially in the case of prolonged diseases. As a result, many diseases that usually do not have dire consequences on the health of Bulgarians in general become chronic for a large number of Roma or have a negative impact on other organs.
According to the data from the comparative survey Health and the Roma Community: Analysis of the situ- ation in Europe, 28% of those surveyed suff ered some type of indisposition such as a cold, virus or some other disease forcing them to reduce their main activities in the two weeks preceding the interview. This is a very high number and is just one more indicator of the severe morbidity situation facing the Roma com- munity. The elderly and children were the most vulnerable age groups: 39.6% of Roma over 45 and 38.2%
of children aged 0-9 had been sick. Type of housing seems to be a signifi cant factor accounting for higher morbidity: the proportion of people suff ering from diff erent symptoms in the two weeks leading up to the interview was highest among those who lived in sub-standard housing (36%) or in shanty towns (32.4%).
Children most frequently suff ered from the common cold, fl u and cough. Adults suff ered more symptoms indicative of diff erent diseases: heart disease, bone and joint disease, kidney problems, nervous system disorders or viral diseases.
This survey showed that 12% of the entire Roma population (including children) suff ers from some type of disability or from a serious chronic disease. One peculiarity which is characteristic of the Roma community is early disability and widespread chronic disease as early as middle-age. One third of men and two fi fths of women age 45–60 have partially or entirely lost their ability to work due to poor health. The proportion of those suff ering from chronic disease or disability in the over 65 group rises to 70%. Three fi fths of the men and three quarters of the women claimed they have some chronic disease or are disabled.
The survey showed that the size of settlements, the area of residence (integrated or isolated) and housing type are also signifi cant factors leading to higher levels of disability. Some of these factors also entail other signifi cant processes such as poverty, poor education and poor access to medical services. Rural popula- tions face many diffi culties in gaining access to medical services and suff er higher levels of long-term un- employment and poverty. The proportion of people who suff er from chronic illness or who are disabled is highest among rural Roma. In contrast, Roma living in Sophia have a better chance to be diagnosed and obtain a disability certifi cate. That is why the proportion of disabled among this latter group is the highest and the proportion of those who suff er from chronic illness but are not categorized as disabled is lower.
Many diff erent obstacles are faced in obtaining a medical disability certifi cate. A serious problem is that sick people have to submit to a huge number of medical examinations which are expensive and are not covered by the Public Health Service. This fi nancial problem is particularly critical in the case of the poor who face permanent and high expenses for life-support medicines. Another problem is connected with the admin- istrative organization and bureaucracy surrounding medical services acting as a particular barrier to the illiterate and, once again, the poor. The third problem is that in many places the regional medical centres have closed down and sick people have to use the services of what is known as the Expert Physicians Com- mission in Sophia or other distant cities. Because of this, the poorest sick people cannot obtain a disability certifi cate and are therefore deprived of social pensions and a series of other benefi ts provided for people who cannot ensure their income because of health problems.
Accidents in the Roma community are commonplace. During the 12 months immediately preceding the interview, 12.2% of all those surveyed had suff ered an accident. This fi gure was double (21.3%) in the case of older children (10–15 years of age). Particularly surprising was the fact that more women than men fall victim to accidents. About half of the injured women and children had suff ered domestic accidents. This in an indirect indicator of the spread of domestic violence in this community.