SAMPLE EXCERPT:

The 'average" Roma household usually has a somewhat flexible membership. This is due to the fact that Roma generally have large extended families. The tradition of living together dates back to the days when members of a family would all share one camp, eating and sleeping at family members homes as if they were there own. The males work in groups of relatives and friends. They are handymen, the solicit repair jobs for cars, buying and selling cars, or helping women in their fortune telling business. The females share a storefront office or room where they tell fortunes. Roma prefer to keep to them and avoid contact with other members of society.

One of the most important things that a health care professional needs to understand when working with Roma is this. For the Roma, illness is not an individual problem. The sick person is not the only one suffering; the ill person is not the sole concern. For the Roma, illness is social, a problem of broader importance than just the individual. News of a serious illness within the family will hasten everyone in the family to the bedside of the ill patient. This gathering is not just a socially mandated gathering, it also stems from a genuine concern for both the sick person and the immediate family of the ill person. As stated earlier, the care for extended family and clan members, as shown through the coming together when someone is ill, is one of the strongest values in Romani culture, one the pervades all tribes no matter their location.

In order to properly care for the Romani, a health care professional must have a basic understanding of the basic beliefs and behaviors of the Romani as it relates to sickness and health as well as the social and cultural context of healthcare. As mentioned earlier, for the Roma, the understanding of health and sickness is closely tied to the cultural understanding of purity, and impurity, good luck and bad luck, cleanliness and uncleanliness (see table 1).

Good fortune and good health are closely associated for the Romani. Their common blessing, "may God give you luck and health," demonstrates that connection clearly. Those who have good health have also been blessed with good fortune. Those who are sick have somehow lost their good luck. This is one of the reasons people gather when even an extended family member is ill. To some extent, the ill person, the one who has lost his/her good fortune, can in turn, ruin everyone's luck. By their own actions they encourage health or cause their own illness. Sickness is caused when a person performs actions that can be considered polluting or contaminating.

The way to become well again is to return to a state of purity. This is accomplished by and conforming to acceptable social behavior. For example, a teenager who is rebellious is in danger of polluting him/herself through sexual relations can be "cured" by marriage.

Perhaps the most frustrating belief health care professionals encounter is that the larger, or fatter, a person is, the luckier, healthier, and happier that person will be. Fat people are though of as healthy and fortunate. Conversely, a thin person is pitied as either ill or too poor to eat, both of which indicate a lack of good luck. Family wealth and fortune is also partly due to luck, according to Romani tradition, because although each family develops similar job and economic skills, some have more luck than others. Some families enjoy good health, grow to a large size, and prosper, whereas others are plagued with illness, family and money problems. People then must take action to change their own fate and fortune. Personal cleanliness, proper social attitudes, and behaviors including generosity and virtue, bring good luck. Generally speaking, traveling as opposed to living in one place is thought by the Romani to be good luck.

Marime, in the Romani language, means polluted, defiled, or unclean. The word is used to indicate uncleanliness or impurity of a physical as well as a ritual or moral nature. Being marime or unclean can bring about bad luck and poor health. In order to be "clean" the top half of the body from the waist up must be kept separate from the bottom half of the body, which is considered, polluted and is an area associated with feelings of shame. The source of pollution of the lower body is the genital/anal area and its emissions and secretions. Secretions and emissions that come from the top half of the body are not considered shameful, indeed they are seen as clean and can be used as cures.. For example, spit is though of as a clean and curative substance that may be used to clean cuts or scratches. This viewpoint conflicts with medical practice, which sees spit as a possible source of contagion. Separate soap and towels are used on either the upper or the lower part of the body, and these towels must not be allowed to mix. Bathing in a hospital can be easily accommodated to Romani's belief by making sure they have separate soap and towels for the upper and lower portions of the body. Romani believe that not keeping these two areas separate everyday can result in serious illness. Many guidelines are used to keep the upper half of the body separate from the lower half and therefore pure.

At the very least, it is important to wash hands after touching the lower part of the body and before touching the upper part of the body. It is important for health care professionals to respect this rule too, making sure to change examining gloves when going from an examination of the lower part of the body to the upper part of the body. Furthermore, most Romani women will not agree to a gynecological examination or a Papanicolaou smear off hand. However, if the attending health care professional will take the time to explain the importance of such an examination, a Romani will usually agree.

Marime can also mean rejection because to become physically or morally impure could mean being rejected by the entire group. Rejection is a serious punishment for a Gypsy because it means social isolation.

This is another reason for the coming together of the family, to assure the ill and the immediate family members of the ill person, that they are not being rejected.

The idea of body separation has other implications for the treatment of Roma at hospitals. For the Roma, the most important distinction is that between Roma and non-Roma. Non-Roma do not observe body separation and are therefore a source of impurity, disease, and bad luck. Public places where non-Roma predominate such as public toilets, hospitals, buses, schools, offices, jails, and non-Roma homes are also potential sources of disease. All these places are less "clean" than the home of a Gypsy or open outdoor spaces such as parks and woods. When they must be in non-Roma places, Romani generally avoid touching as many impure surfaces as possible, but, of course, prolonged occupation of a non-Roma place such as a hospital means certain impurity. In this case the person tries to lessen the pollution risk by using disposable paper cups, plates, and towels -- that is, things not used by non-Roma.

This also has implications in terms of controlling the many people that appear when a Romani is admitted to a hospital. It is better to be on the grounds than in a hotel, or hospital.

In all this it is important to remember that it is not the case that Romani do not care for their health or fitness, indeed it is scene that they care very much for their own personal health and the health and luck of their family, from the oldest to the youngest, even though these practices do not seem to meet with popular medical convention of what is healthy.

Concern for a person's health begins at birth and is most active during the days or weeks of confinement (from 9 days to 6 weeks) of the mother. In the past, infant mortality for Roma has been very high. This may be somewhat improved nowadays because more Roma women re deciding to give birth in hospitals; however, the crucial period of prenatal care is still entirely neglected because few women will accept a vaginal examination. One of the reasons Roma have turned to hospital birth is the advantage to them of avoiding the impure placenta birth substances.

After the period of pollution of birth has passed (more or less 6 weeks), children are considered pure in body and action. Children are free from most social restraints and are not expected to understand or demonstrate "shame" in their actions. Physical contacts defiling to adults are not necessarily defiling to children, who need not take many of the precautions that adults do to…