"I have diabetes. I get free therapy. The doctors said that I have to change my diet completely, but I can't afford it," he told the Center for Investigative Journalism of Montenegro (CIN-CG) Ema (real name known to the editors). She is a woman from the Egyptian community. He is 35 years old. She gave birth to three children and is currently pregnant with twins. As he speaks, he sits on the floor next to the wood-burning stove in a modest, but neat and clean room. Her disabled mother-in-law is lying on the bed. He speaks quietly and seriously, getting up every hour to look carefully at his lunch.
Emi's sugar, as she says, is often around 20, which is almost four times more than the normal value. This disease, if not treated, can cause a series of serious, even fatal complications: heart and kidney diseases, vision problems, gangrene...
Due to her twin pregnancy, Emma needs additional calories. "I eat everything I ate before the diagnosis: bread, pasta, legumes. The doctors forbade me all that. After a meal, I take an insulin injection, that's all I can do," she explains.
Roma and Egyptians in Montenegro live an average of about 55 years, which is about 20 years shorter than the majority population. There is no serious analysis of why this is so. Such a short life expectancy is typical for the poorest countries in the world, such as the Central African Republic.
"Women from the Roma and Egyptian population in Montenegro live shorter lives than men due to the large number of childbirths and a difficult life while raising a larger number of children," she told CIN-CG. Melissa Spahic, a doctor of family medicine who works at the Podgorica Health Center, in Konik, where these populations make up the majority of patients.
This, explains Spahić, is the observation of doctors in Montenegro, but he states that no research has been done on the lifespan of Roma and Egyptians based on gender.
This trend is not typical - women from the majority population in Montenegro as well as in the world live on average about five years longer than men.
CIN-CG has already written about the fact that Roma women in Montenegro start having children very early, often as minors, that they give birth to a significantly larger number of children than women of the majority population, that medical control of their pregnancies and reproductive health is often absent. Because of all this, they suffer chronic health consequences at a relatively young age.
A 2018 UNICEF survey in Montenegro showed that 36,9 percent of respondents in the 20-24 age group gave birth to at least one child before their 18th birthday.
Research by the Center for Roma Initiatives (CRI) in the Riverside neighborhood from 2022 showed that some of the stateless women had never seen a gynecologist, that they gave birth at home, and that doctors had a discriminatory attitude towards them even in emergency situations.
"I gave birth to two children that I didn't even register in the birth register at home because they brought me back from the hospital, due to lack of documentation, even though I told them I was in severe pain. My mother-in-law and daughter-in-law gave birth to me," is one of the confessions from the research.
Several global studies confirm the negative consequences of having a large number of children and giving birth at a young age on women's longevity and health.
A 2016 study by the University of California on a sample of over 20 women showed that women who give birth to their first child after the age of twenty-five live longer than those who give birth earlier.
A large number of births affects both health and longevity even after the age of 50, i.e. after the end of reproductive years, shows a large study from 2016 that followed life expectancy in the American state of Utah since the 19th century. It was concluded that men lived longer than women in that climate until the end of the 19th century. Women began to live longer on average only after the reduction of uncontrolled births, but also thanks to the improvement of medical care.
Poverty and chronic diseases - an inevitable connection
The problem that has the greatest impact on a shorter life span is chronic diseases such as cardiovascular, diabetes, hypertension and so on, says Dr. Melisa Spahić.
"The Roma and Egyptians generally do not move enough, they eat unhealthy food. It is difficult in their situation to afford a healthy and varied diet. They live without basic conditions. Because of all this, a number of diseases occur, and the so-called metabolic syndrome, which implies a problem with obesity, is characteristic. sugar, high blood pressure, fatty liver, heart," explains Spahić.
"I'm overweight, I have a hormonal problem. I can't lose weight. It's hard for me to stop eating sweets," she tells CIN-CG Enisa (real name known to the editorial staff), a girl from the Roma community whose name is known to the editorial staff. She is only 18 years old. Does not work. He's mostly home. He lives in the dilapidated Roma settlement Riverside in Berane.
He suffers from insulin resistance, a condition that can lead to diabetes, and metabolic syndrome. She can't afford a healthy and regular menu either. "I eat sweets, I eat bread. Sometimes I'm very hungry, but that's all there is at home," says Enisa.
Data from the 2019 Global Burden of Disease, led by the Institute for Health Metrics and Evaluation at the University of Washington, show that women are generally at greater risk of disability from chronic diseases, have higher mortality from diabetes and cardiovascular disease, and more years of life with disease consequences. Cardiovascular diseases are the leading cause of death in women worldwide, followed by stroke.
All studies conducted in Montenegro indicate that Roma and Egyptians suffer from chronic and infectious diseases much more often than the majority population.
A 2018 UNICEF survey in Montenegro showed that a fifth of Roma children under the age of five lag behind in development. In the majority population, such a condition is present in three times less children. Over 95 percent of children under the age of two are behind in development, and almost 80 percent of them are malnourished.
People of low socio-economic status have a 46 percent higher risk of early death than those who are in social care, according to a study by Imperial College London on a sample of 1,7 million people.
Several global studies have shown a strong connection between poverty and chronic diseases. People with low incomes are more likely to suffer from cardiovascular diseases, diabetes, and cancer, according to a statement from the US National Institute of Health (NHI). As much as 30 percent of the risk of chronic disease comes from stress due to poverty, which is not related to poor diet and lifestyle. Stress leads to a decrease in immunity, which then leads to illness, NHI explains.
Poor housing conditions are linked to asthma, cardiovascular disease, mental illness, infections such as tuberculosis, colds, stomach problems and injuries, according to the World Health Organization (WHO) in its statement.
Spahić explains that Roma and Egyptians often do not understand how the health system works: making appointments, keeping track of examination dates and times, buying medicines.
"For chronic diseases, deterioration of the picture is typical, so proper therapy and visits to the doctor are necessary," explains Spahić.
A significant part of the Roma and Egyptian population does not have access to health care and insurance due to unregulated legal status or avoids using health services due to discrimination, and they do not have a sufficiently developed awareness of health care, according to the Strategy for the Social Inclusion of Roma and Egyptians (2021-2025) of the Government of Montenegro .
Roma generally do not know about associates in the field of health
"I almost had a heart operation," the thirty-five-year-old tells CIN-CG Anisa (real name known to the editorial staff), a Roma woman from Beran, who has been a heart patient for four years.
"Recently I had a worsening of my health, the matter became urgent, so I could not wait for an examination at the state hospital, which was only scheduled for May," she says.
As she says, she had to shell out over 150 euros for the private recording, but also pay for transportation to Podgorica, where the clinic is located.
Only 10 percent of Roma and Egyptians are aware that there is an associate in the field of health in their community, according to the Strategy of Social Inclusion of Roma and Egyptians in Montenegro (2021-2025). Of them, only a fifth used this service, and about half believe that it can be useful for them.
"We help colleagues from other cities to schedule several specialist examinations on the same day at the Clinical Center so that the travel costs of these people, who mostly live on social assistance, are as low as possible. In particularly difficult cases, we also manage to provide home visits and care and assistance ", he says for CIN-CG Milica Vujadinović, associate in the field of healthcare in Podgorica.
Within the Ministry of Human and Minority Rights, 21 collaborators work in the inclusion of Roma and Egyptians in three areas: health care, social care, employment and child protection. There are nine of them on the territory of the capital.
The associate provides assistance in exercising the right to health care, scheduling examinations, handing over documentation for consultations... explains Vujadinović. "Every day we help children who don't have a card to be examined at the Institute of Children's Diseases," she says.
"It is clear that the system with that number of associates cannot provide assistance to everyone from the Roma and Egyptian population, and that is why it is of crucial importance," explains Vujadinović, "that the position of associate becomes a systematized job position, which is not the case at the moment."
The Ministry of Human and Minority Rights told CIN-CG that the aforementioned associates were engaged only until January 2024. "The Ministry of Human and Minority Rights and the international humanitarian organization HELP will appeal to the Government of Montenegro to systematize jobs for a certain number of associates at the Ministry of Labor and Social Welfare, the Ministry of Health and the Employment Office or, if possible, to systematize all jobs for all associates," they stated.
Educated mothers - healthier children
According to the Strategy of Social Inclusion of Roma and Egyptians in Montenegro (2021-2025), the goal is to increase the average life expectancy of Roma and Egyptians. Thus, in 2023, it is predicted to be around 57 years, and in 2025, around 58 years. These figures have been reduced compared to the original draft of the Strategy, when the life expectancy for 2025 was predicted to be 61 years.
"Education is closely related to how someone will take care of their health, explains Dr. Melisa Spahić. Literacy is necessary for understanding key information, and Roma and Egyptians in Montenegro often do not even have a basic education, or do not even speak the language of the majority.
And UNICEF research from 2018 showed that the level of education of mothers in these populations is closely related to the health of their children. Thus, among mothers with secondary or higher education, there are no children who lag behind in development, while among mothers without any education, this percentage is around 25 percent.
The program of the Institute for Public Health of Montenegro (IZJZ) provides some of the guidelines for dealing with Roma and Egyptians. This program advises doctors and community nurses "to look at all components of the life of the Roma and Egyptian community", and accordingly "indicate the principles and importance of a healthy diet, reflecting food safety", and that doctors respect WHO guidelines, that "it is carried out continuous assessment of children's health status", using parameters of obesity.
CIN-CG contacted the health centers in the municipalities with the largest populations of Roma and Egyptians with the question of whether they follow the recommendations of the IZJZ. The answer came from the Ulcinj and Nikšić Health Centers, from where they claim that control of obesity parameters in children is carried out, and that Roma and Egyptians are informed about the importance of a healthy diet like everyone else.
"Every doctor who is guided by the basic principles of the profession will inform the patient. However, the medical system cannot provide everything that members of these populations lack in order to fully improve their health," concludes Spahić.
Emma, from the beginning of our text, her three children and her mother-in-law, who also suffers from chronic diseases, are supported by her husband, who works at the Podgorica Municipal Company. After paying the installments for the loan they took out to repair the house, they only have 250 euros left. The minimum consumer basket in Montenegro for a household of four is about 800 euros per month. With so little money, who will think about Emma's diabetes and the food she needs.
Bad treatment in the field of healthcare
"When I go to the doctor, they shout at me, they tell me when you take out the booklet, come for an examination. Our health workers will see you if you want to die, they will not examine you", said one of the research subjects of the Center for Roma Initiatives (CRI) in the Riverside neighborhood in Berana from 2022, which dealt with reproductive health.
According to this research, many women are discriminated against in health institutions, and since a large number of them do not have proper documents and a health card due to statelessness, health workers almost always refuse to treat them. Because of this, some of the respondents did not see a doctor for years, gave birth at home, and bought medicine on their own. "I've never been to a gynecologist because I don't have a document, and I don't have the money to pay privately. I gave birth to six children alone, two of them died," says one Roma woman.
"I've been married for fifteen years and I don't have children, and I don't know why I don't have them. I don't go to the doctor, because I don't have a health card, I couldn't get treatment," said others.
"A large number of Romani and Egyptian women do not submit complaints or petitions in the event of a violation of a right or discrimination in the medical system because they do not recognize such mechanisms," according to CRI's research.
Bonus video:
