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RESEARCH: Jeffrey A Kelly, Yuri A Amirkhanian, Elena Kabakchieva, Sylvia Vassileva, Timothy L McAuliffe, Wayne J DiFranceisco, Radostina Antonova, Elena Petrova, Boyan Vassilev, Roman A Khoursine, and Borislav Dimitrov Prevention of HIV and sexually transmitted diseases in high risk social networks of young Roma (Gypsy) men in Bulgaria: randomised controlled trial BMJ 2006; 0: bmj.38992.478299.55v1 [Abstract]

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Distorted priorities in the development of preventive strategies?

John W Powles   (24 November 2006)

Poverty and infection – perpetuating the stigma

Boika Rechel, Bernd Rechel   (1 December 2006)

Distorted priorities in the development of preventive strategies? 24 November 2006
John W Powles, Senior lecturer in public health medicine Institute of Public Health, Cambridge CB2 2SR Send response to journal: Re: Distorted priorities in the development of preventive strategies?	Dear Editor Prevalence surveys based on blood testing have found zero cases of HIV infection among samples of Bulgaria's Roma population (1). Comparative risk assessment for Bulgaria by WHO (2) estimates that health losses (DALYs) from smoking are 10 times higher than those from unsafe sex and health losses from high blood pressure are nearly 40 times higher, with substantial losses also from high blood cholesterol, low fruit and vegetable intake and physical inactivity. There is little evidence that public health authorities in Bulgaria are devoting proportionate effort to the development of preventive strategies for these other much more substantial risks. Are Bulgarians allowing their research and development efforts in public health to be distorted by the availability of external funding? John Powles Institute of Public Health, Cambridge, UK CB2 2SR jwp11@cam.ac.uk (1) Varleva T. Epidemiology of HIV/AIDS in Bulgaria (1986-2006). In: Proceedings of conference: Challenges of delivering health in the enlarged Europe - experience and perspectives from member states and accession countries, Sunny Beach, Bulgaria September 29 to October 1, 2006. 2006; p. 54 (2) Personal communication, Dr Colin Mathers, Evidence and Information for Policy Cluster, WHO, Geneva, 2005. Competing interests: None declared
Poverty and infection – perpetuating the stigma 1 December 2006
Boika Rechel, Clinical Academic Fellow in Public Health Medicine School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, NR4 7TJ, Bernd Rechel Send response to journal: Re: Poverty and infection – perpetuating the stigma	Dear Editor, While the risk of HIV spread in Bulgaria should not be ignored, this paper perpetuates a dangerous tradition of scapegoating the victims of discrimination and exclusion. Most published research on the Roma in Central and Eastern Europe has focused on communicable disease and the threat of contagion, indicating a greater concern with the majority population than with the health of the Roma. (1) There are many important and pressing health challenges facing the Roma in Bulgaria, but most stem from poverty, poor living conditions, and discrimination in the spheres of education and employment. The Roma have been one of the losers in the years of transition to a market economy, and most are now poorer that they were when the democratic changes began in 1989, with many confined to urban ghettoes with little hope of benefiting from the EU accession of the country in 2007. (2) The paper has the potential of doing more harm than good. Poverty related diseases (such as tuberculosis) are a much bigger problem among the Roma than HIV, but unfortunately do not seem to be as attractive for foreign investigators. Only recently, between June and September 2006, there was a large outbreak of Hepatitis A in Plovdiv’s Stolipinovo ghetto, one of the largest Roma ghettoes in Southeastern Europe. It took the Bulgarian authorities several months to react to the disease outbreak and start immunization measures and activities to improve sanitary and hygienic conditions. (3) Addressing the health needs of Roma in Bulgaria and the rest of Central and Eastern Europe needs to take account of their socio-economic and political situation and should not be confined to communicable diseases. Too often, Roma have been the mere object of administrative measures and scientific research, with no regard to ethical questions. HIV is highly stigmatized disease and associating Roma with it runs the danger of perpetuating stereotypes and discrimination. Unfortunately, the authors have paid little regard to such ethical questions. They have failed to identify an independent ethics committee in Bulgaria. Instead, ethical approval to conduct this research was given by a small NGO, whose director and chair is one of the authors. This raises important issues about the ethics of international collaborative research. Boika Rechel, School of Medicine, Health Policy and Practice, University of East Anglia, Norwich NR4 7TJ, UK B.Rechel@uea.ac.uk Bernd Rechel, European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK Bernd.Rechel@lshtm.ac.uk (1) Hajioff S, McKee M. The health of the Roma people: a review of the published literature. J Epidemiol Community Health. 2000 Nov;54(11):864-9. Review. (2) UNDP. Avoiding the Dependency Trap - A Human Development Report on the Roma Minority in Central and Eastern Europe, United Nations Development Programme (UNDP), 2003. (3) WHO Communicable disease surveillance and response, 27 September 2006 - Hepatitis A in Bulgaria, Plovdiv Region - Update 1, http://www.euro.who.int/surveillance/outbreaks/20060927_4 Competing interests: None declared