In the spring of 1998, we carried out
an empirical research on the topic of the health of the Hungarian Gypsy
population. Because of the restricted budget of the survey, and even more
because of my personal interest and professional background, I chose a
social-psychological approach to the topic. We decided to observe the relationship
between young pregnant Gypsy women, young mothers with small children,
and the representatives of the health care system, focusing on several
issues. The problem of this relationship seemed to be relevant for several
reasons:
1. Prevention is the most important factor of effective health
care. Caretaking of pregnant women, providing adequate conditions for childbirth
and the care for young children, and the ability to recognize illnesses
as early as possible, are the main items in that process.
2. Care for pregnant women and young mothers is a proper field for our
purposes because this field is one of the best documented in Hungarian
health care, where each member of the concerned population has contact
with health care representatives.
3. Finally, the topics of childbirth, pregnancy, and procreativity of
the Gypsy population are very much associated with their poor health conditions,
with their short life-expectancy in comparison to the majority population,
etc.
Typical explanations of this phenomenon are the higher rates of premature
birth, in connection with early, frequent or late deliveries, and consequently,
dystrophy, mental and physical disabilities, and sensitivity for several
illnesses occuring among Gypsies.
It is a legitimate question why this well-covered field of the health
care system where representatives have in every case a personal contact
with their patients, is not more effective, why it is not able to intervene
in these negative phenomena, and why have not more significant changes
occurred in the last few decades.
According to our hypothesis, besides the well-known
social, financial, economic and educational disadvantages of the Gypsy
population, and the special case of health care (as in education), poor
communications between Roma women and health care representatives contributes
to the lack of success. Interactions and communications lead to misinterpretations
on both sides, which result in deepening mistrust, and consequently, the
effectiveness of curative support is weakened. But inadequate communication
can have a further consequence in health care. Troubles and misunderstandings
occur in an "authority-client" relationship. In an optimal case, uniform
care as a universal condition could strengthen equality for everyone, otherwise
it may increase segregation and marginalization of Gypsies, instead of
helping them to integrate into Hungarian society.
We wanted to analyze the relationship between the two sides. Therefore
naturally, we wanted to have information about both sides. The method of
our research was interviews, hoping that this would lead us not only to
discover facts, but opinions, explanations, and beliefs, as well. We questioned
persons in health care who were in everyday contact with Gypsy mothers:
district nurses, midwives, gynecologists and family doctors. From the other
side, we interviewed 80 mothers of four sub-samples, 20 women in each group.
The four groups were selected by ethnic background, choosing the three
major Gypsy ethnic groups in Hungary: Vlach, Boyash, Romungro (Hungarian
Gypsies or musicians), and as a fourth, so-called control group, the Gypsies
of Budapest were selected.
The topics of the conversations were the history of pregnancy, childbirth,
the care for the newborn baby at home, and curing their illnesses. Neither
representatives of the health care system nor the Gypsy mothers were considered
by us to be more objective in any given topic. We assumed that both health
care representatives and Gypsy respondents based their experiences, or
"knowledge", on personal events, individual experiences constructed by
their own wider and narrow communities' values, explanations, and habits
(professional in the former case, traditional in the latter). We also assumed
that narration of any topic would not be equivalent, communication between
the two sides would result in misunderstandings and misinterpretations.
But because of the fact that Gypsy mothers are seeking advice, help, and
care by health care representatives, who - according to their profession
- intervene in order to lead their patients to a required behavior, inaccurate
communications hindered the effectiveness of care.
Questions of our research included the following:
1. Whether stagnant and poor morbidity and mortality rates
of the Gypsy population can be a result of inadequate communications between
health care representatives and Gypsies?
2. What is the relationship between health care representatives and
Gypsy communities with different ethnic backgrounds?
3. Is there any conflict between prescriptions of health care representatives
concerning life patterns, health conceptions, etc., and that of Gypsies,
based on their own traditions?
4. Does the knowledge - facts, beliefs, prejudices - about Roma play
any role in the relationship of health care representatives and Gypsy clients?
The main difference in the perception of health care
representatives and Gypsy mothers we observed was in the field of procreativity.
Medical doctors, nurses, and midwives mostly assumed that the fertility
of Gypsy women is due to their lack of family planning, ignorance, poor
education, etc. - they are only living their biological life, surrendering
to their natural and unconscious destiny. Gypsy mothers in their eyes are
so-called "natural human beings", "wild-women", a population in transition
from a semi-civilized life to "normal" culture. Elements of that "wild-women-ness"
are an early sexual life, easy pregnancy and delivery, prolonged breastfeeding,
etc. In their opinion, the obstacle of giving them information and advice
originates on one hand from a real communication gap, sometimes because
of their different language, sometimes only because of their under-education.
On the other hand, they observed Gypsies' theatricality, their over-sensitivity
to recognizing prejudice everywhere, etc. They admitted to not having enough
knowledge about Gypsies, and some of them also admitted that persons in
the health care system have prejudices against different people, especially
Gypsies. They have not learned to handle these difficulties, never having
learned any communication or conflict-solving techniques.
On the other side, in interviews with Gypsy mothers, we observed a duality
of effects behind their family planning processes. This observation was
based on the analysis of the whole sample and by comparing the four different
sub-samples. This duality of effects, two different vectors sometimes functioning
in parallel, sometimes in conflict with each other, is a scale of tradition-modernity,
and a scale from spontaneity and ignorance at a high level of consciousness.
This duality is present in every case, and it is sometimes difficult to
separate this two different kinds of influences on fertility. If we suppose
that in Romani communities high numbers of children in families and an
acceptance of fertility without any consideration is typical, it is useless
to expect a rational choice according to the majority's opinion in family
planning. Logically speaking, we may assume that on the one hand a high
number of children per family in a traditional community is a rational
choice, while in the same community a low family size can happen only by
chance, or is a deviant behavior according to tradition. On the other hand,
among families without strict traditional customs, a low number of children
is a sign that these families followed the norms of the majority, and the
high number of children is deviant. Not only traditions, but ignorance,
the above mentioned spontaneity, or "primitivism", can influence fertility
rates and can hinder the educational work of health care authorities. In
these cases individual destiny is relegated to biology, to social influences
without the possibility of self-defense.
We do not believe that majority of our respondents live in this way.
It is true that women in our sample are different in their fertility habits
from the average Hungarian women. This difference is significant only in
the case of Boyash and Vlach Gypsies, but in these two sub-samples different
causes are working in the background. On the scale of tradition, Vlach
Gypsies are more traditional, with large families and higher numbers of
children due to their rational choice. In this group family planning and
the use of contraception (artificial abortion, as well) is more frequent
than in the other groups. The sub-sample of Boyash Gypsies seems to be
more dependent on their biological fate. Abortion did not occur in this
group, family planning is unknown, or only after several children did they
decide to use some contraceptive method, sometimes following the advice
of the health care representative. In the group of Romungro Gypsies, like
in the Budapest control group, although the average number of children
is higher than in the whole population, this number and their attitudes
are not different from the similar stratum of Hungarian families characterized
by the same level of education, working situation, and social situation.
The Budapest group showed the highest level of consciousness in family
planning, although they started to plan their fertility after the first
or second child, usually giving birth at a very young age. Members of this
group had a very mixed ethnic background and many of them came from unstable,
broken families, sometimes spending their childhood in state-run institutions.
Their fertility habits are mostly influenced by non-traditional mediators
such as age-group, neighborhood, school, media, and following the norms
of the majority in the field of family planning.
We were aware of being only able to give a non-representative
report about the contact between Gypsy mothers and representatives of the
health care system. Our first statement is that these two sides are from
two different environments. The two kinds of narration about the same life-experiences
of these mothers seemed to happen in different universes. According to
the interviews made among health care representatives, the Gypsy population
is something very different from the whole society, they are in between
primitivism and civilization. Interviews with Gypsy mothers convinced us
that the sample is very mixed but does not deviate much from the social
stratum which has the same social characteristics. What is different, is
that these women suffer by the simultaneous claim of the broader and the
narrower community to follow their norms, and these two sometimes contradictory
effects can result in a conflicting perception of their procreativity.
We also observed that the myth of "wild-women" influenced the self-perception
of Romani women negatively.
Ignorance, spontaneity assumed by health care representatives seem to
be true only in one part of the sample. In the majority of cases when we
observed fertility habits different from the majority, it was due to the
traditional values. Only in the smaller part of the sample did we experience
that ignorance or subversion to biological destiny was the reason for early
childbearing or for the high number of children per family.
A third element of the health care authority observed was prejudice
in Romani client relationships. Our interviews with health care representatives
expressed this prejudice only in a few cases, but in their discourse, in
their expressions, we discovered a kind of prejudice which appeared toward
the image of "wild-women", under-civilized people. But they also accused
their clients with such characteristics as aggression, over-consciousness
of their differences, and that they assumed prejudice even where there
was only an expectation of "normal" behavior. Interviews with Gypsy mothers
convinced us that their everyday experiences with health care representatives
is that they feel perceived through the prism of prejudice, instead as
individual beings with their own behaviors, problems, that they are only
members of a discriminated group.
Neither the group of health care representatives, nor the group of Gypsy
mothers was homogenous. Even the small group of health care representatives
justified that the higher the contact with Gypsies, the more personal and
adequate was their perception of Gypsies. The seldom and low-rate contact
of health care workers with Gypsy clients leads to a mythical perception
of that population, full of prejudices and misunderstandings. That means,
district nurses had the most empathetic and understanding relationships
with their clients, and only this group seemed to be able to adapt themselves
to Gypsies' traditional or community-based habits. Gynecologists, medical
doctors in hospitals had the greatest distance from their Gypsy clients
and their false views led them to construct a wall of prejudices.
Inconsistency of Gypsy attitudes was due to our method, choosing four
groups of different ethnic backgrounds. In comparison to the uniform image
of health care authorities, we observed four widely differing groups when
considering habits in choosing partners, family planning, fertility customs
and child rearing, from the point of view of spontaneity-consciousness
or tradition-modernity. Differences in these groups and the similarity
of behavior of health care representatives called our attention to the
fact that a universal-rational approach of experts and the prejudicial
view of Gypsies results in inadequate communications in the majority of
cases.
Finally, we suggest considering one more point. We did not seek to analyze
Gypsies' perceptions of health care workers, our purpose was only the comparison
of two points of view of the same events: pregnancy and childbirth by Gypsy
mothers, and their child-rearing habits. We assumed that adequate communications
and effective advisory work is only possible if the two images created
by the two different sides overlap each other, in other words, if the expert
knows his or her patient in an objective way. We did not intend to analyze
the Romani's "doctor-image". However, several experiences mentioned in
the Gypsy interviews called our attention to one danger, that advice, instructions
and directions of health care representatives can only be effective if
the person giving them is trustworthy and genuine. The Gypsy experience
of a thoughtless, negligent, or inept medical doctor, working only for
extra money, can only lead to a false over-generalization of health care
representatives, hindering effective medical advice and treatment, damaging
efficient doctor-client relationships.