Travelling on

Travelling people make up Europe’s largest ethnic minority. Thomas Mac Mahon takes us through their world and points out the health obstacles they encounter in their journey

Try to think when it might have been acceptable to talk about people like this: “It is a life worse than the life of beasts … One of the surprising things about it is that not every individual bred in this swamp turns out bad.” And, “Many of these so called travellers seem to think that it is perfectly OK for them to cause mayhem in an area, to go burgling, thieving, breaking into vehicles, causing all kinds of trouble, including defecating in the doorways of firms and so on, and getting away with it.”

1850? 1900? 1950? How about 1996 and 1999, respectively? If these comments had been made about any other ethnic group they would have been greeted with an outcry (and probably would never have been made in the first place), but because they referred to the travelling community they were not seen as equally controversial. Clearer illustrations of the recent remark by Sarah Spencer, deputy chair of the UK’s Commission for Racial Equality, that “discrimination against gypsies and travellers appears to be the last ‘respectable’ form of racism”^w1 would be hard to find. That a senior British politician, Jack Straw, was responsible for the latter observation is all the more surprising.^w2

Travellers are still portrayed in the news as dishonest thieves: in the run-up to the last UK general election, Michael Howard, former UK Conservative party leader, even promised to repeal the Human Rights Act to end perceived abuse of planning laws by travellers.^w3 These headlines obscure the fact that they have real health needs that rarely feature during our long induction into a caring profession.

The long and winding road
Kern Robinson/panos

Travelling people

With 200 000 to 300 000 travellers and gypsies in the United Kingdom, 30000 travellers in Ireland, and 5 million Roma in central and eastern Europe, collectively the travelling people make up Europe’s largest ethnic minority.^w4 Nevertheless, research into factors affecting their health has been limited and has often concentrated on the Roma population. In the United Kingdom, a 1999 policy document targeting socially excluded groups failed to mention them at all^w5; it was only two years ago that a report was released to try to redress this imbalance.^w6 In Ireland, where travellers make up a greater proportion of the population, research has been more extensive and has been confirmed by the UK findings.

So what is the reality facing the traveller community? Take a cursory glance at their population pyramid and you would be forgiven for thinking it referred to a developing country. Forty per cent of Irish travellers are under the age of 15 (compared with 20% for the whole population), and only 3.3% are aged 65 or over (in contrast to 11.1% generally).^w7 They are therefore dying much younger than most of the population, with higher death rates for all causes of death. Having survived from birth, with an infant mortality twice the national average, through infancy, where the rate of sudden infant death syndrome is more than 3.5 times the national figure, and into adulthood, male travellers overall have a life expectancy roughly 10 years lower than their settled counterparts; life expectancy for female travellers is 12 years lower.^w8 From these figures, Irish travellers are only now reaching the life expectancy that settled Irish people achieved in the 1940s. This differential is mirrored in travelling populations across Europe.

Health determinants

Why does a differential exist? Firstly, imagine living in a muddy polluted field on the side of a road, with no electricity, running water, or sanitation. Many travellers face these appalling living conditions, which are among the most important factors affecting their health and are associated with a high incidence of stress, infectious disease, and accidents. To add to this, general practitioners are generally reluctant to visit halting sites, particularly unofficial roadside ones.^w9

In 1986 it was observed that: “The circumstances of the Irish travelling people are intolerable. No humane and decent society, once made aware of such circumstances, could permit them to persist.”^w10 Twenty years later, 601 Irish traveller families (11% of the total) are still living on unauthorised halting sites or on the road side^w11;the proportion is similar throughout Europe. National governments are making efforts to improve their accommodation by providing standard housing, where travellers choose to live in council estates alongside non-travellers, as well as permanent, fully serviced halting sites and group housing schemes, where houses are built on a site specifically for travellers. However, even official halting sites can be poorly serviced and maintained and situated in unsuitable locations.^w6 Progress is impeded by the general housing shortage in Ireland and the United Kingdom and, more importantly, by hostile and occasionally violent reactions from local communities where travellers are housed.

But while their living conditions, combined with the more subtle factors of racism, exclusion, and disadvantage,^w12 are by far the largest influences on their health, health services also contribute to their poor health.

Attitudes of general
practitioners and other patients

A recent study found that 17% of travellers had difficulty in registering with a general practitioner, and often only a small number of general practitioners provide services to travellers. When assessing their use of hospital services, 35% reported experiencing discrimination.^w9 Also, members of the settled community often refuse to share a waiting room with travellers. This can make healthcare staff reluctant to accept traveller patients and is exacerbated by the fact that manyrelatives accompany sick members of this community, leading to overcrowding. Recently, the problem of practitioner prejudice has been recognised, but difficulties with access remain.

Culture

A traditional health service is inflexible and poorly equipped to deal with the mobile subset of the traveller population. Although it is incorrect to assume that travellers cannot travel and remain healthy, mobility does have implications for the maintenance of medical records, communication, and correspondence with patients and follow-up at outpatients. Opportunities for advice, support, and preventive care may be missed, with symptoms of important diseases possibly going undetected.

On a more mundane level, the close inter-relationship of many traveller families and resultant duplication of first names and surnames can cause confusion when trying to identify patients.

Possible solutions

Only in the past decade have some solutions to these problems started to materialise.

Partnership

The Primary Healthcare for Travellers project, which started in 1994 as a joint initiative between Pavee Point Travellers Centre and a Dublin health board, recruits and trains community health workers from within the traveller community. They then help to train other health professionals, developing health education and health promotion programmes specific to travellers, researching traveller health status and needs, and representing them to the media and to government. As Missie Collins, one of the participants in the scheme, says: “This is the first time travellers have got this type of training and job. We understand our own people and believe that given the proper support and resources we can begin to improve the health of our community. It is no longer acceptable that travellers die so young.”^w13

The project was presented with a World Health Organization award in May 2000 and a Guinness Living Dublin award in 2002 as a sign of its success. Some centres in England, notably Cambridge, Newark, and Leeds, have adopted this partnership approach as a model of goodpractice.^w6

Government policy

Recognising the failures of health policy towards travellers, the Irish government and traveller groups drew up Traveller Health: A National Strategy 2002-2005 as a blueprint for delivering culturally appropriate health care while remaining careful not to foster segregation. The document acknowledges the effects of racism, social exclusion, and accommodation conditions on ill health, stating, for example, that “an immediate improvement to the living environment of travellers is a prerequisite to the general improvement in health status.” It also emphasises the importance of partnership and advocates the replication of the Primary Healthcare for Travellers project wherever there is an appreciable traveller population.^w14

Proposals to cover all aspects of traveller interaction with elements of the healthcare system are included. These range from altering general practitioners’ contracts to limit the circumstances in which they can refuse to register a traveller patient, to an expansion in the numbers of designated public health nurses and the development of patient held records. €8.25m (£5.6m; $10.0m) was set aside to pay for the recommendations it contains, but while over 40 primary healthcare projects have been set up, progress with implementing other aspects of the strategy has been mixed and often painfully slow. Even so, recognising at government level that the travelling community has specific needs has been an important step. There have been calls for other governments to take similar action.

As individuals

As mentioned in a UK report,^w6 if all doctors and health staff were “trained to respect people” then there would be less need for dedicated services for travellers. Guidelines and training schemes have been introduced to combat racial prejudice and foster cultural awareness,^w15 but this is exactly the sort of touchy-feely area from which many students recoil. However, it is worth remembering that poor service from the education system has contributed to the situation where illiteracy is estimated to be a problem for 80% of traveller adults. Simple things such as explaining instructions verbally or pictorially may improve compliance. Traditional health promotion campaigns that do not take these factors into account are likely to be equally ineffective—videos and posters rather than leaflets have been shown to be the most important media for conveying health messages.^w14 As is often pointed out, advocacy is another area where doctors can make important differences.

Conclusion

There has been an increased recognition of the specific health needs of the travelling community in the United Kingdom, Ireland, and across Europe, but it remains unlikely that the life expectancy differential can be reduced when their standard of accommodation remains poor. The impact of the daily discrimination they experience from the settled community will be even harder to address since changing public attitudes will require generations. Medical professionals can be powerful advocates on their behalf in the healthcare setting.

I thank Helen Campbell, Exchange House Travellers Service; Catherine Joyce, Irish Traveller Movement; Stephen Monaghan, Parish of the Travelling People; and Brigid Quirke, Pavee Point.

 

 

Thomas Mac Mahon, intercalating medical student, University College Dublin
Email: Ireland tomacmahon@hotmail.com


studentBMJ 2006;14:89 - 132 March ISSN 0966-6494

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