Traveller gypsies have resided in the British Isles for over 500 years, making them one of the largest ethnic minorities. They experience widespread prejudice and discrimination from the settled population. Health care for traveller gypsies has resulted in poor access to services and relative neglect of their health needs. This essay will focus on inequalities in health experienced by gypsy and traveller communities also discuss why they occur and will critically discuss the various national and local initiatives that have helped to improve the health of gypsies and travellers.
The travelling lifestyle itself is not necessarily a cause for the disparity in health status; on the contrary, many Travellers and those working with them see the reduced opportunity to live their traditional lifestyle as a major cause of increased physical and mental ill health.
travel experience frequent fear and the reality of constant evictions and alienation of local people. In decades gone by Travellers were often welcomed for the trades and services that they provided to the local community, such as fruit picking, scrap metal dealing, etc. They had their traditional stopping places; most of which have now disappeared, along with some of the opportunities for casual work.
Poverty has sometimes been cited as the main cause of poor health in this group. Economic hardship. Lack of education is another factor that can adversely influence health. Low literacy attainment is still a major problem for most adult Travellers, mainly because so few attended school on a regular basis, if at all.
The 1996 Ofsted report stated that of an estimated 50 000 Traveller children aged 0-16 years as many as 10 000 secondary school aged children were not registered at all, and attendance by the remainder was considerably below the acceptable standard for settled children.16There are many reasons, apart from the obvious one of mobility, for the reluctance of Travellers to send their children to school, especially after they have passed primary school age. Some of the reasons are cultural, such as the tradition that from the age of about 12 the children need a family education to understand and take on roles and responsibilities within the family. Formal education still has little relevance to a culture that has always relied on practical skills and self employment. Often there is a fear about assimilation; that the children will not only be educated out of their culture but also that they may pick up different and unacceptable moral values. Parents are also often anxious about bullying and prejudice. Attendance is also affected by the need to participate in all the many cultural and religious events.
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No community is immune from child abuse and it must be acknowledged that abuse could more easily go undetected in the Traveller community. Traveller culture deems that they sort out problems without help or perceived interference from outside. There is historical distrust of social workers because many Gypsies and Travellers throughout Europe have lost children into care, usually because of lack of support for their lifestyle, rather than as a result of evidence of child abuse. However, Travellers view child abuse as totally abhorrent and most would claim that it does not exist within their culture. Most professionals working with Travellers would agree with Cemlyn17 that there appears to be less evidence of child abuse in the very child centred Traveller community than in the non-Traveller community. Travellers do tend to be strict disciplinarians but there is also a high level of physical affection within families.
Enlightened social services departments, such as Bromley, recognise the Traveller lifestyle and state that they take Traveller culture into consideration in their assessments and are careful to offer support. It is recognised that there is a strong cultural expectation that Travellers stay at home and learn their roles full time from early teens and girls in particular carry out domestic tasks and help rear their younger siblings from an early age.18
Griffiths illustrates this with a quote from a mother about the best way to keep her baby amused: “just love it, kiss it, talk to it and cuddle it”.19 However, Griffiths and Arnold also point to children who do appear to suffer from emotional neglect, either because there have been too many siblings too quickly, or because mothers suffering from their own problems, such as domestic violence, deprivation and depression, are too absorbed in their problems to meet the emotional needs of their children.19
There are other factors that affect the health status of Travellers. A national population based study of health of Irish Travellers showed a greater prevalence of congenital anomalies in Travellers compared with Irish Eastern Health Board region births (5.5%v 2.9%) and a significant difference in the prevalence of metabolic conditions with autosomal recessive inheritance (12.4/1000 v 1.3/1000). The incidence of first cousin marriages in the Traveller population was 19% compared with 0.16% in a settled population.14 Families at risk require culturally sensitive genetic counselling to enable them to make informed decisions. The Traveller community perceives substantial economic and social advantages in these consanguineous unions (A Bittles, 1996, personal communication).15
Access to health care
Poor access to health care is the almost universal experience of Travellers; inequality in the availability and use of health services in relation to need is in itself socially unjust and requires alleviation.20 The alienation and discrimination experienced by Travellers is one of the most important factors influencing their health: “the central problem for the Traveller population in this country is the hostility of the settled population”.13 This hostility is expressed by all levels of society and is seemingly reinforced by successive government policies. The Criminal Justice and Public Order Act 1994 recently removed rights and introduced new penalties for travelling, thus effectively criminalising their nomadic way of life.22
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The experience of trying to obtain health care can be extremely humiliating and rejecting. It increases stress and can cause a potentially serious delay in receiving appropriate treatment. Travellers often lack information about services, partly because of literacy problems. Many general practitioners will not have Travellers on their lists. A survey in East London showed that 10% of practices would not accept them at all.23
Blatant prejudice about Travellers is evidently politically acceptable, although a similar policy about black patients would be treated as racial discrimination. Missed appointments are a frequent source of irritation to health care providers, but appointments might not be received when the family has no postal address or has been forced to move to another area. The situation has worsened since the introduction of the Criminal Justice and Public Order Act 1994. Travellers are now moved on much more quickly (often just by threat of enforcement), which adds to their problems in keeping medical appointments. Professionals are often reluctant to offer further appointments even when the family want to attend. Travellers fear being detected too quickly by authorities because of the risk of eviction, so the first contact with health workers may be when a child has to be taken to the local hospital.
In some areas, where there are major difficulties, a salaried general practitioner approach is now being piloted for Travellers and homeless people. The obvious advantages are that the general practitioner is freed from financial concerns in meeting targets and can build up a trusting relationship with the Traveller community. Usually, the salaried general practitioner will have chosen to work with this group, as will the rest of the primary care team, and therefore be culturally sensitive and more readily understand their circumstances and concerns. Continuity of care will be more likely because of the trust engendered. It is also more likely that preventative services will be accepted because the surgery will be less likely to be seen as a “crisis only” venue. Although it can be reasonably argued that a Traveller specific service further reinforces the social exclusion of Travellers, until primary care services in general can more readily adapt to Travellers on their lists there will be a continued benefit in provision of salaried general practitioner services.
Other obstacles to provision of health care include different cultural attitudes to precise dates (including dates of birth) and time, and different perceptions of illness and treatment. In a study of Travellers’ perceptions and experiences of health, the concept of time figured frequently and was seen as an important issue.24
Lack of access to medical records affects continuity of care, and the National Association of Health Workers with Travellers (NAHWT) is currently seeking government backing to launch and promote the use of a national client held record for Travellers.
As with other minorities, the first essential is knowledge, understanding, and acceptance of their culture. This helps staff to overcome the various obstacles to health care and to deal with their own exasperation about the perceived lack of conformity in the Traveller community.
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