Recent research into the incidence of tuberculosis (TB) in Irish Travellers in Ireland from 2002 to 2013 found a crude incidence rate (CIR) of TB that was about three times higher in Irish Travellers than in the white Irish-born population. It also found that in Irish Travellers the average age of a TB patient was 26 years, compared with 43 years in the general population in Ireland, and 49 years in the white Irish-born population (1).
These findings raise the question of whether this disparity in incidence is an isolated situation that is specific to TB, or is potentially part of a pattern with regard to a number of communicable illnesses in the Irish Traveller population.
A study from the Health Protection Surveillance Centre reported an elevated incidence rate of invasive meningococcal disease in Irish Travellers (CIR of 10.1 per 100,000 in 2013, excluding outbreak cases) compared with the general population (CIR of 1.8 per 100,000 in 2013) (2).
There have also been reports of significant outbreaks of measles in Irish Travellers that may indicate a greater risk of measles in this population (3).
The All Ireland Traveller Health Study (2010) established that infant mortality rates are approximately three and a half times higher, and that life expectancy at birth is more than 10 years lower in Irish Travellers compared with the national average.
Given that recent data indicates Irish Travellers are also experiencing higher rates of certain communicable illnesses compared with the general population, the next question is whether more could be done to address the stark imbalances in health outcomes between Irish Travellers and the rest of the population.
To answer that, we need to look at what is being conducted in other countries with indigenous ethnic minorities who historically have presented with higher rates of communicable and other illnesses. In Australia, the National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes, agreed by the federal, state and territory governments in 2008, set targets and outcomes that are measured and published annually.
In relation to health, the agreement set a goal of halving mortality rates for indigenous children under the age of five within a decade, and eliminating the gap in life expectancy within a decade.
Social determinants
The Closing the Gap agreement also included specific targets on social determinants of health in particular; education in terms of attendance, literacy, numeracy and attainment rates; and employment. While not all targets have been realised yet, the goals of halving child mortality, and increasing year-12 education attainment (for 17- to-18-year-olds) are on track to be met by their respective target dates.
The use of specific measurables enables the Australian federal and state governments to benchmark progress and regularly evaluate strategies towards meeting designated targets.
In New Zealand, each district health board has a Maori Health Action Plan, which is updated and published annually. The plan includes specific measures to monitor the health outcomes of Maori, sets out its actions to achieve targets, and measures results against indicators of success.
The health indicators are also broken down into specific conditions such as cardiovascular disease, diabetes, respiratory disease, cancer, mental health and associated risk factors.
The Capital & Coast District Health Board Maori Health Action Plan provides a real-world example of devising a comprehensive and cyclical appraisal of indigenous health.
Milestones and indicators
By contrast, the document
Healthy Ireland, A Framework for Improved Health and Wellbeing 2013-2025
, published by the Department of Health in 2013, refers to “targets or sources for development of potential indicators” in relation to Irish Travellers, but it is not clear from the document what those specific targets, or potential sources of indicators, are.
Furthermore, milestones and how they are being met are not provided. Similarly, the document Ireland's National Traveller/Roma Integration Strategy published by the Department of Justice and Equality in 2013 lacks specific indicators of success and corresponding target dates with respect to Traveller health.
The Department of Health's Priority Areas, Actions and Deliverables for the Period 2015-2017 document, published in January 2015, does not include Irish Traveller health as a priority area, although it is among the poorest in Ireland in terms of infant mortality and life expectancy. Building in specific targets, actions, milestone dates, and indicators of success, is an integral part of addressing health disparities in indigenous minorities.
They provide an essential baseline against which a comprehensive range of health indicators, and social determinants of health, can be measured on an annual or other regular basis and help identify the interventions that are most effective in delivering enhanced health outcomes.
Another aspect of Traveller health that requires attention concerns data completeness. For many communicable and noncommunicable illnesses, data on their incidence and prevalence in Irish Travellers is lacking or incomplete.
This serves to make it more difficult to identify areas of disparity, and subsequently, to focus health interventions for the Irish Traveller population where they are most needed. One difference with respect to indigenous minorities in other jurisdictions is that Irish Travellers in the Republic of Ireland are not officially considered an ethnic group.
Uncertainty
This may potentially generate a degree of uncertainty or inconsistency about the need to record Irish Traveller ethnicity routinely as part of public health surveillance across a range of acute and chronic illnesses.
While the recommendation for Irish Travellers ethnicity recognition by the Houses of the Oireachtas Joint Committee on Justice, Defence and Equality in April 2014 stands on its own merits (iti.ms/1qlzaPi), where adopted, it could in effect contribute to better data collection on Traveller health.
Improvements in Traveller health surveillance would represent a significant development in determining the unique set of health requirements of the Irish Traveller population, and in designing comprehensive Traveller-specific health action plans.
Dr Ronan O'Toole is a senior lecturer in microbiology in the school of medicine at the University of Tasmania, Australia. (1) See O'Toole et al, Epidemiology and Infection, 2015. (2)See Cotter et al, Epi-Insight 2014. (3) Cohuet et al., Epidemiology and Infection, 2009; HPSC Annual Report, 2010.
