The Roma are the largest ethnic minority in the European Union. Although published figures vary, reflecting differences in survey methods and definitions used, they are estimated to number between 5 and 10 million people in the 27-country European Union (EU) as of 1 January 2007. Although Roma can be found throughout the EU, they are concentrated in Hungary, Slovakia, Romania and Bulgaria.1 In addition, sizeable populations live in the non-EU countries of south-eastern Europe, such as Serbia and Macedonia.

Concerns about the status of the Roma population have led to the inclusion of a specific requirement to protect the rights of minorities in the criteria established for European Union enlargement in 2004,2 with the European Commission continuing to monitor their situation.3 This concern stimulated the creation of a partnership in 2003 involving eight governments in the region, relevant international organisations (eg the World Bank and the United Nations Development Programme) and non-governmental organisations (eg the Open Society Institute). This partnership, designated the Decade of Roma Inclusion,4 seeks to close the gap between the Roma people and their compatriots in four areas; employment, education, housing and health.

In this paper, we are concerned with the last two of these. It is apparent that the Roma suffer considerable disadvantage with regard to housing.5 Many live in segregated communities, termed colonies, that comprise buildings of very poor quality and with few basic amenities.

It is also apparent that they are disadvantaged in terms of health.6 7 The reasons are many, including worse environmental conditions, unhealthy lifestyles (such as high levels of smoking and poor nutrition) and substantial obstacles to obtaining effective care (such as bureaucratic barriers to enrolling in statutory health insurance schemes and outright discrimination).8^–12

The association between poor housing conditions and ill-health is well established, and although there is relatively little experimental evidence on the health benefits of improved housing, what exists indicates a positive effect.13 14

Heads of governments made certain commitments when they signed up to the Decade of Roma Inclusion and to accession to the EU. They also have certain obligations under international law to ensure social and economic rights.15 16 It is important that their policies are judged against these commitments and obligations. Health impact assessment (HIA) can offer a means of contributing to this process.

In this paper, we describe an assessment of the health effects of a proposal by a local government to evict a Roma community from their dwellings. This was a highly contested move, on many grounds. One of these was a concern about health. On the one hand, the housing was seriously substandard, with few facilities, so it was argued that any realistic alternative would contribute to better health. On the other hand, there were concerns that eviction would disrupt social networks that support this community. Furthermore, any alternative would not necessarily be better for health.

The HIA was embedded within a community development project involving a broad partnership that included the School of Public Health of the University of Debrecen, several statutory agencies and non-governmental organisations, and the Roma community itself. This was initiated in 2003 and the HIA was undertaken in 2005 when it was proposed that the community be evicted.

METHODS

This study was approved by the Regional and Institutional Research Ethics Committee of the Medical and Health Science Center of the University of Debrecen, Hungary.

Setting

The School of Public Health of the University of Debrecen became involved in this process when it conducted an environmental survey of Roma colonies (defined as settlements consisting of at least four dwellings that are demonstrably substandard from the viewpoint of environmental hazards and public utilities compared with other dwellings in the same city or village) in Hungary between 2000 and 2005. Two colonies in the second largest city of the country (Debrecen) were identified; the community identified first was invited to enter a pilot community-development project (Box).

This community comprised 70 people, including 25 children. Two years into the project, the local government, which owned the houses in which the community had been squatting for more than a decade, filed and won a lawsuit that would permit eviction of the community from these buildings. They would then be placed on a waiting list for subsidised social housing, although with no guarantee of when this would be available or whether the community would remain intact.

Implementation of the HIA

An HIA is a combination of procedures or methods by which a policy, programme or project may be judged in terms of the effects it may have on the health of a population.17 This HIA was based on the model of health set out in the Ottawa Charter of Health Promotion, according to which health is the process of enabling people to increase control over and to improve their health, based on prerequisites such as shelter, education, social justice and equity.18 Taking into account the differences between Roma and the majority population in culture, perception and attitudes,19^–21 our HIA consciously adopted a fully participative, inclusive and multidisciplinary approach using a range of methods to assess effects on health. The baseline situation and the nature of alternative scenarios were identified using qualitative and quantitative data collection, and the plausible health effects were assessed using relevant evidence from research and incorporating the perspectives of those involved.22

The HIA was initiated by the research team of the School of Public Health, University of Debrecen following the commencement of the legal procedure for eviction. It lasted for 5 months, from August to December 2005. Workshops were conducted with members of the Roma community, who were fully involved in the design of the project; public-health professionals working in the area, statutory and non-statutory support organisations (local family help service and child protection service), and teachers in the kindergarten and school attended by children from the community. The general practitioner caring for the community and the local government area representative were also interviewed.

Scenarios

In consultation with the community and relevant officials, two basic scenarios were identified. The first, eviction, involved simply removing the community from its current buildings and, owing to a shortage of social housing in the city, placing families on the waiting list for social housing (henceforth labelled “eviction”). However, this would also be expected to lead to some of the children being taken into care, at least temporarily, while their families were homeless. The second envisaged the creation of a new housing project, either on the same site or elsewhere, that would maintain the coherence of the community (henceforth labelled “housing project”). However, the latter would obviously be more expensive, requiring a combination of bank loans for eligible families with small children as well as contributions by the city government, the national government and private funders. Thus, it was considered important to inform the debate by comparing the health impacts of each approach.

Data collection

Data collection was iterative, with qualitative and quantitative data collected during visits to the community, workshops, focus groups and in semi-structured interviews with community members and professionals.

Quantitative data on community members were collected by means of interviews, with questions on demography, education, employment, income, health behaviour and health status. The questions, adapted for face-to-face administration, as many community members are illiterate, are based on items from the Hungarian National Health Behaviour Survey and include the Beck Depression Scale (BDS) and Antonovsky’s Sense of Coherence scale.

Qualitative data were collected by means of in-depth interviews, community meetings, focus groups, participatory observation and thought experiments (eg drawing of life scenes) that would yield insights into the community’s opinions on potential changes in their lives in the event of different future scenarios.

RESULTS

Community profile

Debrecen is the second largest city of Hungary with approximately 204 000 inhabitants23 of which 8–9% is estimated to belong to the Roma minority.24 The community in question consists of 15 families (70 people, all identifying themselves as Roma) living in a segregated location in one of the industrial zones of the city. In total 29 (42%) members of the community are male and 25 (36%) are <18 years of age. Over half (53%) of the adults served a term in jail. Ten of the families constitute an extended family network, and three others are more distant relatives. There are some internal conflicts, related to heavy alcohol consumption by some members and to borrowing of money.

The houses in which the families are squatting (one of the 15 families has legal tenancy) are owned by the city authorities and once served as temporary dwellings for workers in a nearby, now defunct brick factory. The community moved into the derelict houses several years ago (in the case of one family, 20 years ago) and the buildings have long been registered as each individual’s permanent address by the city authorities. Until September 2005, the authorities had made no attempt to reclaim the houses or evacuate the community from these dwellings.

The settlement, in a disused industrial zone, lacks paved roads. It was difficult to move around after rain because of the deep mud. Of the 15 families, 13 have ⩾4 members. In total, 13 families live in houses with one room, and 2 in houses with two rooms. The buildings are uninsulated, leaking and often damp. Their whitewashed walls are repainted occasionally by their inhabitants. There are no door-locks. None of the houses has an electricity supply or running water; instead, water is obtained from a communal pump. They are not connected to the sewage system and there is no rubbish collection. There are infestations of rodents and insects, and the surrounding area is characterised by rubbish deposits scattered among animal shelters (pigsties, henhouses, kennels) that are in close proximity to houses.

Only 65% of the adults have completed primary school (8 years of education), and 31% of those aged >14 years are functionally illiterate. No-one in the community is in permanent employment but some do obtain temporary jobs. Many also derive some income from scavenging for scrap metal and cardboard. All families receive social benefits, but 50% have a family income (average family size five people) of < €55/month (average monthly income for the mainstream population in Hungary is €655).

Formal tests of significance are of little value because of the small numbers involved, but in all respects the health of the community compares extremely unfavourably with that of the majority Hungarian population. Furthermore, it is relatively poor even when compared with other Roma colonies; 28% of adults have longstanding limiting health problems, compared with 21% of those in a representative survey of Roma colony dwellers in Hungary.7 There is a high frequency of childhood illnesses, especially respiratory, gastrointestinal and skin infections. Injuries are common, including scalding and rodent bites (two children in the past year). In all, 88% of adults smoke, again much higher than those living in Roma colonies in general, where the total prevalence was found to be 62%,7 50% of adult community members are depressed according to the BDS, compared with 27.3% in the Hungarian population.25

Comparison of scenarios

The potential effects on health of the two scenarios (eviction and implementation of a housing project) are presented in table 1. Table 2 presents the expected consequences of the two scenarios for the various organisations with an interest in this issue.

DISCUSSION

This HIA identified numerous positive health effects and some uncertain and probable negative effects of the proposed housing project versus eviction. The findings reflect a substantial consensus among those consulted and are consistent with the research evidence. Interventions to improve housing frequently do result in health improvements, although the precise contribution of better housing, which is often only one part of a regeneration intervention, cannot always be established with certainty.26 27 The HIA also provides evidence that, save in exceptional circumstances, such as the appearance of significant funding that would make possible greatly improved alternative accommodation, eviction offers no concrete benefits for the health of the community involved. The only significant beneficiary is the city government, which, by evicting this community, can reclaim its property and will be able to transfer much or all of the cost of its social support to other municipalities or to the national government. However, eviction would maintain or even aggravate the disadvantage of the Roma community, now and potentially in future generations. Although it was always apparent that it would conflict with the commitments in relation to housing made by the Hungarian government when it joined the Decade of Roma Inclusion, this assessment demonstrates that it would also be incompatible with commitments regarding health and, although not the primary focus of this assessment, to some degree regarding education and employment.4

Like most HIAs, this project is limited by the speculative nature both of the characteristics of the two scenarios and of many of their predicted effects, the latter being aggravated by the scant research literature on the health impacts of housing projects, with none in Roma communities in central Europe. Nonetheless, given the intensity of the process undertaken, it is possible to be reasonably confident of the outcomes of the different scenarios, while recognising the potential for completely unanticipated developments to occur.

Its strength is the degree of involvement by the Roma community, which has in the past often been justifiably suspicious of outsiders.28 The community development project in the framework of which this HIA was conducted has made it possible for the researchers to get to know the community very well, ensuring that the factors of most importance to them were adequately explored. Furthermore, by including the full range of support organisations (statutory and non-statutory) in the HIA, it was possible to incorporate a wealth of information that facilitated specification of the features of the two scenarios and the likely consequences of each of them.

It could be argued that, given the nature of the alternatives on offer, an HIA was superfluous. However, despite the obvious short-term material consequences of eviction for the community, not all the parties concerned accepted that this would have consequences for health, not least because the situation they were already in was so appalling. This echoes the now infamous comments of Barbara Bush who suggested that some of the poor African American population displaced following Hurricane Katrina might actually be better off than they had been in New Orleans.29 In a context in which the poor health of the Roma minority is at least officially accepted as a matter for public policy concern, it became important to ensure that those proposing eviction were forced to confront the possible health consequences of their actions.

The process of undertaking the HIA, with its fruitful collaboration between researchers, public-health professionals and support agencies working with the community was itself beneficial, highlighting issues that might have been overlooked, such as some of the financial costs and benefits. Furthermore, it is important as, to our knowledge, it is the first example of a participative HIA undertaken with a Roma community in this region. For this reason we believe that it is important to make this experience known so as to provide encouragement for others to undertake similar exercises. This is particularly important given the growing international attention to the plight of the Roma, which can be expected to increase the funds available for projects designed to improve their wellbeing. It will be essential that these projects are evaluated in terms of their potential impact on health. The experience of completing this HIA provides a demonstration of how Roma communities can be full participants in health research rather than, as has often been the case in the past, simply the passive subjects of it.7 28

The ultimate goal of a HIA is to help policy-makers make better decisions. At the time of writing (January 2007), it has been possible to postpone the eviction and preparations are now underway to establish a broad-based consortium to address the housing problems facing the community. The HIA, by placing the health of this community firmly on the policy agenda, has at least delayed any precipitate action and will contribute to the deliberations of the consortium as it seeks an appropriate solution.

This project also serves as a reminder of the importance of mandating HIAs before policy decisions are taken. It is almost incomprehensible that a policy that would have rendered an already disadvantaged community homeless might have been undertaken without any consideration of the consequences for health, whereas anyone seeking to establish a storage site for scrap metal would have been required to undertake an assessment of its potential effects on the environment.30 HIA remains relatively underdeveloped in central and eastern Europe (although also in many parts of western Europe).31 This HIA only took place because of an existing collaboration between public-health researchers and the affected community. We contend that there is a need to make HIA a statutory requirement, as is the case with environmental impact assessments, and at the same time provide the available resources needed to make it a reality. It would then provide an important means of mitigating the effects of policies in other sectors that would otherwise exacerbate the persisting health inequalities that exist in this region.

The information gathered during this assessment only provides a snapshot in time. The story they begin to tell is not yet finished and its plot cannot, at the present time, be foreseen. However, whatever happens, it does provide an important baseline against which to assess any change in the circumstances of this community. Even more importantly, it will facilitate an evaluation of whether the predicted consequences of one of the scenarios will come about. In doing so, it will strengthen the evidence base for future HIAs involving the Roma and other disadvantaged populations.