The Iztok Campaign

The following article, supported via a grant from the OSI Roma Health Project and the Media Program, originally appeared in Transitions Online.

PAZARDZHIK, Bulgaria—Entering Iztok you immediately feel the difference. Music blares, barefoot children scramble underfoot, and young people sit in ramshackle cafes. If it’s warm, the odor of sewage and uncollected garbage lingers.

As many as 25,000 people live in Iztok, one of the largest Romani neighborhoods in Bulgaria. People from all walks of life make their home here on the outskirts of the city of Pazardzhik—owners of the latest model Mercedes cars, middle-class families, and people struggling for physical survival.

The deeper you penetrate into the neighborhood the worse it looks. In Tokaito, the poorest of the eight mahalas, or quarters that make up Iztok, unpaved streets narrow to dirt tracks traversed by horse carts. When it rains the tracks turn to mires.

The other mahalas have better infrastructure, paved streets, and sewers in some areas. But there are Roma in Iztok living in conditions not even suitable for animals, according to Vasil Petrov, Iztok’s only health mediator. Mediators serve as liaisons between health workers and people living in Bulgaria’s poorest neighborhoods.

“Poverty forces them to live in dirt, disease, and misery,” he says.

The potential for living conditions to contribute to poor health is hard to ignore in Tokaito, where children play in a waste water ditch flowing down the middle of the road. Vendors alongside the ditch offer fruits and vegetables, bread and other produce for sale. Iztok residents are prone to such poverty-linked ailments as hepatitis, tuberculosis, and tapeworm, and also suffer from above-average rates of heart and circulatory disease, diabetes, and kidney disease, according to a survey by the Napredak (Progress) Foundation, an organization that works with local Roma.

In theory, medical care is close at hand. The city emergency medical center is only 300 meters from Iztok, but people from the neighborhood say ambulances often refuse to drive inside. Although Tokaito and other interior areas do pose serious challenges for motor vehicles, most of the area is accessible to ambulances.

Iztok residents allege that conflicts with doctors are not rare. “My child was 6 months old when she came down with a high fever, about 40 degrees Celsius. … I grabbed my daughter and ran to the emergency unit,” Minko Minkov says. The 39-year-old has worked on Romani education and civil rights issues for a decade and helped open Napredak. “There was a line of 15 people, but they let me cut the line. The doctor was smoking outside the center. He kept smoking and sent me to the hospital at the other end of town.” But the state hospital 3 kilometers away sent him and his daughter back to the emergency center, he says.

“The doctor saw me and started shouting at me. I started running towards him. Out of fear he hid and made the nurses take the child from me,” Minkov says.

The girl was eventually given treatment, but Minkov wonders why he had to rush around town and make a scene in order to get his child the free emergency care all Bulgarians are entitled to.

Officials at the nearby emergency center deny there is a double standard for people in Iztok. “If there is a specific case when a doctor on duty refused to visit a patient, let them prove it. We always strive to be correct and effective in our work, because human health is at stake,” says the emergency center’s director, Dr. Nadka Pangarova.

Self-Help

While Iztok residents may complain about the level of health care, a project designed for the neighborhood is helping raise awareness of how to prevent and control HIV/AIDS and other sexually transmitted diseases. The project began in 2004 as part of a five-year, $15.7-million countrywide grant to the Health Ministry by the Global Fund to Fight AIDS, Tuberculosis and Malaria.

“In the beginning it was very difficult to work with people. They hadn’t heard of condoms, and discussion of sexual relations was taboo,” says Boris Matev, Napredak’s coordinator for the Iztok HIV/AIDS project.

As Matev’s team of five Roma and a non-Romani psychologist crisscrossed the neighborhood dispensing advice, people began to talk more often and more openly about sex and their work became more effective, he says.

In late 2006 Napredak opened a health center at its headquarters in Iztok, the biggest such center in the country. Pazardzhik city hall provided the building and the Health Ministry funded remodeling. The center offers free anonymous tests for sexually transmitted diseases and hepatitis. Iztok residents can also get health advice on the street from Matev’s traveling team.

The center also holds weekly presentations by public health workers and arranges consultations with medical specialists.

People in Iztok may be at greater risk of many health problems than other Pazardzhik residents, but one catastrophe seems to have passed them by, at least so far. About half the neighborhood’s residents have been tested for HIV without a single positive, Matev says.

The zero rate of positive HIV tests points to the significant impact of the prevention work, says Marian Kamenov, an Iztok resident and a consultant to the HIV project. Kamenov says health workers go through the mahalas handing out 20 to 30 condoms a day and asking people about any health problems. Kamenov and Matev both say that more and more people, both singles and couples, are dropping by the center for condoms or to ask about safe sex and other health concerns.

Kamenov also points to cooperation with neighborhood leaders as a reason for the project’s success. By persuading respected Iztok residents to work with the project and giving them training in the basics of HIV education, Napredak was able to reach deeper into the community, he says.

So far, Bulgaria has seen very few cases of HIV—just 689 reported infections by the end of 2006, according to the United Nations office in the country—but Roma along with injecting drug users and sex workers are considered at risk, with worrying levels of hepatitis C and syphilis. A survey by the World Health Organization in 2004 estimated that 0.3 percent of the country’s Roma were HIV-positive, up to three times as high as in the overall population.

Early detection is central to any strategy to limit the damage from HIV/AIDS, TB, and other diseases of poverty. But most people in Iztok don’t have a family doctor or insurance, health workers say. Although health insurance is mandatory and people receiving unemployment payments have their premiums paid by the state, the jobless lose this support after several years. Many Roma lose their health insurance in this way unless they keep up the monthly health payments of around 3 euros themselves.

People in the neighborhood often seek medical help only when complications arise, but in this they are typical Bulgarians, according to the director of the state hospital in Pazardzhik, Dr. Petko Mitev.

“Most people in Bulgaria don’t take action when the first symptoms of illness appear, and the greater part of the Roma in Iztok is in this group,” Mitev says. However, “whether or not patients have health insurance, in the doctor’s office everybody receives help,” he added.

Ignorance and Fear

“The most important problem here is the total ignorance about health rights and obligations,” Kamenov says. One of the few Iztok residents currently at university, he studies preschool and primary school education at Burgas University.

“Most people are unemployed and don’t have health insurance. To a certain degree, poor education leads to poor health culture, which leads to poor hygiene and a high mortality rate among elderly people and children,” he says. “Almost nobody has preventative medical checkups. People struggle to survive every day and they see a doctor only when it’s an emergency.”

Petrov, the health mediator, says parents must take part of the blame for children’s ignorance about health.

“Some parents don’t act appropriately when their children get ill. They just expect their kids would get better without taking actions. Very often they ignore their health problems,” he says.

His neighbors “die because they don’t care about themselves and live in squalor. And the doctors don’t treat us as people,” says Slavcho Angelov, 30, owner of a small cafe in the Yabulkite mahala. The tall father of two also sells fruit and vegetables, but says can’t afford to live outside the quarter and worries about his children’s health.

“I wonder why the politicians don’t get embarrassed. Every time an election is coming up they promise the same old thing. Every time they come to our dirty mahala, they promise to improve the conditions, but alas,” Angelov says.

“They shake their heads with concern and then pay for votes. The major problem is still the same—Roma stay the lowest and most humiliated people in the country.”

Ognyan Isaev is a journalist for the weekly Pokazatel in Shumen, Bulgaria.