Health inequalities experienced by Gypsies and Travellers

Taken together, the findings from the quantitative and qualitative strands of the 2004 studyFootnote ² suggest that there are striking inequalities in the health of Gypsies and Travellers, even when compared with people from other ethnic minorities or from socio-economically deprived white UK residents groups. Gypsies and Travellers are significantly more likely to have a long-term illness, health problem or disability which limits their daily activities or work. They have a greater prevalence of self-reported chest pain, respiratory problems, arthritis and anxiety and depression. Maternal health is also significantly worse, with a significantly higher number of miscarriages. The increased risk to maternal health was also identified by the report of the Confidential Enquiries into Maternal Deaths in the UK 1997–1999, which found that Travellers have ‘possibly the highest maternal death rate among all ethnic groups’ (Lewis and Drife, Reference Lewis and Drife2001: 41).

Prior to the 2004 study, there had been a dearth of reliable research evidence on the health status of Gypsies and Traveller (Doyal et al., Reference Doyal, Cameron, Cemlyn, Nandy and Shaw2002). However, Feder (Reference Feder1994), argued that the detrimental effect of enforced mobility and poor site environmental standards were central to the mental and physical health of Travellers. Other studies also referred to the impact of poor quality sites on both physical and mental health (Durward, Reference Durward1990; Ginnety, Reference Ginnety1993; Gordon et al., Reference Gordon, Gorman, Hashem and Stewart1991; Hawes, Reference Hawes1997; Henninck et al., 2003; Pahl and Vaile, Reference Pahl and Vaile1986). Although Doyal et al. (Reference Doyal, Cameron, Cemlyn, Nandy and Shaw2002) makes clear that there had been no investigation of these links, or of the relationship between health and a nomadic lifestyle in those studies, environmental factors were seen as strongly influential to health outcomes by Gypsy and Traveller participants in the 2004 study. Their accommodation situation was an overriding factor, mentioned by every respondent in relation to questions about their health. Two major aspects were seen as crucial: the specific conditions associated with where and how Gypsies and Travellers live, and the degree of control or choice they have in terms of influencing these conditions.

Gypsy sites policy has historically pathologised aspects of Gypsy and Traveller life, notably those associated with nomadism (Bancroft, Reference Bancroft2000). There is an increasing shift from nomadism towards settlement as a result of the restrictions of current Gypsy sites policy. Lack of choice and lack of control are key features; inability to obtain planning permission for private caravan sites, insufficient provision of suitable rented caravan sites, frequent evictions from unauthorised camping sites, and the combined effects of policy that often results in forced settlement in ‘bricks and mortar’. I will return to the specific detail of health impact, but first I will examine the wider evidence on the relationship between health and accommodation.

Accommodation: a health determinant

Housing has long been recognised as an important wider social determinant of health. Here I use the term ‘housing’ in the broadest sense as described in a WHO Ministerial conference on Environment and Health: ‘the conjunction of the dwelling, the house, the environment and the community’ (Bonnefoy et al., 2004). This wider use of the term is important when considering health implications as it refers to adequate shelter and not simply to a roof over one's head.

The impact of poor living conditions on health, highlighted by public health pioneers Chadwick and Engels, led to the creation of the first Public Health Act 1848 (Stewart, Reference Stewart2005; Shaw, Reference Shaw2004). However, it was not until the late twentieth century, with eventual Government recognition of recommendations in the Black Report on Inequalities in Health,Footnote ³ that serious efforts were made in policy terms to address health inequalities by tackling wider health determinants such as housing. Acheson (Reference Acheson1998), in his seminal report on inequalities in health, identified housing and the environment among a range of areas for policy development, based on their potential impact on health inequalities. This report became the impetus for subsequent health policies with a proactive public health approach (Department of Health, 1999, 2003).

However, although several epidemiological studies have described independent associations between housing conditions and illhealth, the relationship is complex, with much debate and uncertainty about the causal links (Thomson, Petticrew and Morrison, 2001). There are knowledge gaps about the interrelatedness of poor housing conditions and health status and other forms of deprivation, such as poor education, unemployment and social isolation. These data limitations were acknowledged in a longitudinal study of the effects of poor housing on health (Marsh et al., Reference Marsh, Gordon, Pantazis and Heslop1999). Nonetheless, by controlling for other factors the authors concluded that there is a dose–response relationship (the greater the housing deprivation, the greater the probability of illhealth) and that housing history matters; those who have experienced housing deprivation in earlier life are more likely to experience ill health in later adulthood. Shaw (Reference Shaw2004) also identifies several studies in a review of housing and public health to conclude that inadequate housing can have a detrimental effect on both physical and mental health.

The lack of evidence about the exact causal relationship between housing deprivation and ill health makes it harder to assess the effectiveness of any interventions to address housing conditions (Taske et al., 2005). However, the various specific direct and indirect elements of housing that can affect health outcomes have been categorised into three broad groups in the NICEFootnote ⁴ review on housing and public health, with evidence for each of the associations and impact on health cited (Taske et al., 2005):

• • factors which relate to the quality of the internal environments such as indoor pollutants, hazardous structures, cold and damp and noise.

• • factors relating to external social environment such as quality of the neighbourhood and access to amenities, safety and social cohesion.

• • factors relating to macro-policy such as housing allocation, lack of housing, housing tenure, housing investment and urban planning.

We will see how the elements in each of these groups are particularly pertinent to the accommodation experiences of Gypsies and Travellers.

We know that internal conditions on many Traveller sites are hazardous. Ten per cent of amenity blocks on sites are judged to be unfit for purpose, with vermin infestation, damp, lack of heating and poor build quality as commonly reported problems (Niner, Reference Niner2002). However, for Gypsies and Travellers the pitches on the site where their trailer is situated is also as much a part of their internal environment as their trailer and amenity block. The pitches were found to be of variable standard with many being too small and with some where the hardstanding posed various problems, such as unevenness, that could lead to accidents (Niner, Reference Niner2002).

The external social environment of Gypsy sites presents health hazards within site boundaries; for example, lack of footpaths to aid prevention of road traffic accidents, unsafe storage provision for LPG cylinders and lack of basic fire safety standards. There are also many additional health hazards pertaining to development of sites in fringe locations; apart from other housing, they are often in close proximity to motorways or major roads, railways, refuse tips, sewage works and industrial estates. Such site locations are not only a source of distress due to the visual eyesore, noise and disturbance, but they create parental anxiety due to the restrictions on children's opportunities for safe play outside the caravan. A crucial health impact of such site conditions is the impact of social isolation and lack of control to influence these conditions, with the reasoned conclusion that ‘they have been stuck in places where no-one else would want to live’ (Niner, Reference Niner2002: 23).

The group of specific elements relating to broader macro policy affect Gypsies and Travellers in some unique ways. We will see how Gypsy sites policy fails to address the problems of homelessness despite recent policies that oblige local authorities to undertake Gypsy and Traveller accommodation needs assessments. There is also a failure to offer equitable security of tenure on sites with most occupants only given licensee status.

Although there is insufficient evidence to establish a causal pathway between all of these elements of housing conditions and health outcomes, the preliminary analysis of a World Health Organisation housing and health status projectFootnote ⁵ indicates a clear association between mental health and housing quality. Having an adequate home is shown to provide many psychosocial benefits, and satisfaction with the dwelling is a strong predictor of wellbeing (WHO, 2006). This study also found that the perception of control or the ability to influence housing conditions was a significant factor for the prevalence of anxiety or depression (WHO, 2006). The 2004 health status study examined the relationship between health and accommodation type. Gypsies and Travellers living in houses or on local authority sites were significantly more likely to be suffering from a long-term illness than those on a private site or unauthorised site. Those living in houses also had higher levels of anxiety. There is a similar relationship with travelling patterns; those who rarely travelled had a worse health status. As with other studies, causal pathways are not able to be established, and it is not possible to determine from the data whether accommodation and travelling patterns have an impact on health or vice versa.

Drawing on case examples from this study, I will consider the specific health impacts of the various different forms of accommodation available to Gypsies and Travellers as a result of Gypsy sites policy, but first I will discuss the specific feature of lack of control and its health impact.

Lack of control over life circumstances

The impact of environmental or social factors associated with accommodation is strongly influenced by the degree of control or choice available to influence these conditions. Giddens's (1991) definition of ontological security emphasises self-identity and the need of people to be in control of their environment and to feel secure of their place in society. The home has been identified as an important source of ontological security; ‘the home is a site of constancy in the social and material environment . . . a secure base around which to construct identities’ (Hiscock et al., Reference Hiscock, Kearns, Macintyre and Ellaway2001). Ontological security is threatened where there is lack of control in the ability to maintain a secure base or environment that one can call a home and where there is lack of opportunity to exercise autonomy and achieve self-realisation (Hiscock et al, 2001). Giddens argues that ontological security also requires a positive view of the self in relation to others, or, in other words, social status (Giddens Reference Giddens1991). Lack of control over one's life circumstances is a health damaging effect of lower social status (Marmot, Reference Marmot2002; Wilkinson, Reference Wilkinson2005). The cultural importance of nomadism for Gypsies and Travellers is important in this context. There is a strong sense of injustice that ‘society’ does not value their culture and intends them to abandon their nomadic lifestyle. Therefore they perceive that they are seen as inferior through lack of entitlement to equal cultural rights that are afforded to other groups:

Such perceived forced assimilation is viewed as a threat to identity. This threat, combined with the assumed message that a Gypsy or Traveller identity defines you as a social outcast, can have profound negative consequences for emotional and mental health.

Manifestations of low social status are also closely linked to the lack of opportunity afforded for full social participation. The double bind of being socially excluded as a result of a Gypsy and Traveller identity in addition to attempting to maintain a nomadic lifestyle is captured by the Council of Europe:

This dilemma illustrates the social inequality and the resulting social exclusion experienced by Gypsies and Travellers as a result of their stigmatised identity. Social participation is vitally important to identity and in turn to psychological and social survival (Bartley, Reference Bartley2004). This is a crucial aspect of the debates on social inclusion and is emphasised in the aims of the South Australian Government social inclusion initiative: ‘to assist in the creation of a society where all people feel valued, their differences are respected and their basic needs – both physical and emotional – are met, so that as citizens they are empowered in their participation and contribution’ (Government of South Australia, 2007). Gypsies and Travellers are well aware of the hostility towards them collectively from wider society as they experience racial harassment and discrimination in all areas of life. Failure to be granted the opportunity to choose how and where they live is viewed as just one further consequence of this hostility.

Health impact of discrimination

Karlsen and Nazroo (Reference Karlsen and Nazroo2002) suggest that such perceptions of discrimination in wider society may have direct effects on health, with the belief that one is living in a society that will discriminate against you on ethnicity grounds being health damaging in itself. The perception of Gypsies and Travellers that their lack of choice, forced movement and inadequate site provision is a sign of discriminatory social policy is reinforced by the perceived effects of such policies on society's attitudes. Evictions from unauthorised sites, strong, hostile local opposition to any proposed sites, and failure to gain planning permission lead to an even greater awareness of the impact of their racialised identities as Gypsies and Travellers. The social environment resulting from a person's social position produces direct psychological effects that influence wellbeing and are implicated in other causes of morbidity and mortality. It is the social meaning attributed to their environment rather than the material conditions that are crucial. Negative emotions, including depression, anxiety and hostility, that can result from low social status, and related psychosocial factors, may not only lead to clinical mental illhealth but also to suppressed immunity, cardiovascular disease, diabetes and chronic inflammatory conditions such as asthma and rheumatoid arthritis. Prolonged neuroendocrine ‘fight or flight’ responses with raised cortisol levels are deemed to be responsible for these physiological changes (Wilkinson, Reference Wilkinson1996). The potential health impact is particularly evident in psychological terms among children. The impact of accommodation associated with lack of safety and security as a result of racial attacks and general hostility were key findings in a study of views and experiences of Gypsy and Traveller children (Warrington, Reference Warrington2006). Examples are included from Thomas age eight years: ‘getting moved on place to place because nobody wants you and you have nowhere to go and you can be just going round, up and down, looking for somewhere to stay and you have to stay in lay-bys and you get really frightened’ (Warrington, Reference Warrington2006: 68) and Georgina age 14 years, ‘it makes you like you don't want to live anymore’ (Warrington, Reference Warrington2006: 100).

The hostile response towards any possibility of having Gypsies and Travellers as neighbours, whether on unauthorised or authorised developments, is exacerbated by hostile and inflammatory media reports (Commission for Racial Equality, 2006: 13). Councils are frequently reported to respond to high profile campaigns by reneging on tentative plans for local provision of authorised sites. This increases tensions between Gypsies and Travellers and local communities, thus increasing their social exclusion.

Gypsy sites policy, as we have seen, has resulted in increasing difficulty in maintaining a nomadic lifestyle. There is limited availability of pitches on authorised sites and those that are available are often inappropriate for a number of different reasons. Each accommodation scenario brings specific health hazards, described below, but in each scenario the stresses are exacerbated by the dearth of preferable alternatives and the lack of control over their socially deprived situation. The decreased availability of stopping places where their presence is tolerated has meant either continual forced movement or pressure to settle. Lack of control over one's life circumstances, leading to pressure to settle, is intensified by the constraints in choosing where to stay.

The travelling lifestyle – unauthorised camping

In whichever type of accommodation they are living, virtually all respondents in the 2004 studyFootnote ⁶ had at some point experienced the ‘traditional’ travelling lifestyle in a trailer. Almost without exception, it is the traditional travelling lifestyle that is still craved, ‘the travelling way’, although preferably without some of the associated hardships such of lack of access to water. The lack of facilities associated with unauthorised camping would appear to be more crucial today. Morris and Clements (Reference Morris and Clements2002) describe three phases of legislative history as it impacts on Gypsies and Travellers and they describe the present as ‘a period of new intolerance’, where Gypsies and Travellers, rather than the social regulatory system, are viewed as ‘the problem’ (Morris and Clements, Reference Morris and Clements2002: 11).

Freedom and choice and proximity to family networks are cited as particular health benefits that this lifestyle affords; the latter being particularly important in the context of their social exclusion. It is seen as especially important for the children: ‘being outside with a lot of people and that, cousins and friends running around and doing their own thing’ (Bernie aged 30 years now housed).

However, there are various specific health implications for those who attempt to continue living a nomadic lifestyle, but are increasingly constrained by lack of available legal transit sites. Study respondents spoke despairingly of the stress arising from a lack of choice in being able to stay anywhere before being forcibly moved on. The benefits of a travelling lifestyle were, for most, now outweighed by these difficulties. Many gave the main reason for no longer travelling as being the stress of increased law enforcement. This young woman whose poor health precipitated a move into housing explains the stress and the sense of loss resulting from feeling forced to relinquish a nomadic lifestyle:

Many who feel forced to seek more permanent accommodation aim to continue to live in a trailer, a form of accommodation that is strongly associated with the culture. In theory this still affords the opportunity to become mobile again, even if the intention is to travel only for short periods in the summer. However, this choice is made difficult:

There are many Gypsies and Travellers who are still travelling because they are unable to gain a place on the limited number of permanent sites. The lack of suitable places to rent on authorised sites, coupled with lack of transit sites, leads those families with sufficient financial means to buy their own land and to seek planning permission to settle on it; as indeed they have been encouraged to do. However, planning permission is extremely hard to come by for Gypsy and Traveller applicants and this leads to continued establishment of new unauthorised developments (Commission for Racial Equality, 2006: 221). Councils frequently use their powers to evict families. These evictions, while extremely distressing per se, are made worse by the means employed. They are often carried out by hired bailiff companies with a track record of violent evictions (Commission for Racial Equality, 2006: 178). The following web site advert (Land Sheriffs, 2006) is how one such company promotes its services:

Children's fears about safety and security are most marked on unauthorised sites and many live under constant threat and fear of evictions: ‘it upsets me that they might come here with bulldozers’ (Charlene aged 7years) (Warrington, Reference Warrington2006: 69). Forced moves not only create fear and stress from the experience, they also compound a sense of alienation, as they impact on the ability to form friendships and increase a sense of low self esteem: ‘nobody likes Travellers’ (Warrington, Reference Warrington2006: 69). Even when there is notice of eviction and the family are coerced to move, and do so without waiting for the bailiffs, the feelings of fear and of loss for the children are considerable (Children's Participation Project (Wessex), 2007).

This cycle of forced movement, with relocation resulting in further evictions, mirrors the period prior to the 1968 Caravan sites Act (CSA). The CSA was introduced primarily to remedy the endless cycle of evictions and lack of provision that had occurred as a result of the stringent planning controls introduced by the 1960 Caravan Sites and Control of Development Act. However, as we have seen, despite increased site provision since that period, there is still a considerable shortfall. For those that do have a place on an authorised site the choice to live there has often been forced and is by no means an escape from the stresses and health impact of Gypsy sites policy.

Living on an authorised site – the aspirations and the realities

The potential merits or disadvantages of living on a site and relative health impacts perceived by respondents in the 2004 health study varied according to the type of site, the site conditions and the geographical location, as well as whether the site was privately owned or managed by others. The main potential advantage, already discussed, is the option to live amongst other Gypsies and Travellers and, where possible, amongst other family. Respondents spoke of the need to give support and a safe place to stay to extended family members. However, this option is rarely possible because so few vacancies become available. Equally, as older children marry and need a place of their own, they are forced by circumstances to move away from their family support. The lack of choice of close neighbours on a site is a particular source of distress. Site designs afford little opportunity for privacy or opportunity to avoid difficult neighbours.

A supposed benefit of living on a site is improved access to facilities and mains services. However, many sites are poorly serviced, particularly the few transit sites that exist. Distance from health services and other facilities are also common problems arising from site locations. If sites are situated nearer to housing and local facilities, they will often be screened from view, thus further reinforcing a sense of alienation (Niner, Reference Niner2002). Respondents who had been living on a site also spoke of the disadvantage of the cost implications. In contrast to renting a council house, where structural maintenance is included in the rent, the rent for a council site only includes the pitch and any outbuildings and services. The family is responsible separately for providing and maintaining their own trailers (owned or privately rented).

Concerns about health due to the site conditions and the surrounding environment were common experiences. As a direct result of such hazards, children are restricted from one of the desired benefits of living on a site – enjoying the freedom to play outside – as few sites have safe play space provision:

As we have seen in the NICE review such concerns about health implications are valid. Research suggests over 50 per cent of local authority sites suffer from proximity to environmental risks (Niner, Reference Niner2003). For some the conditions on the site, blamed for poor health, precipitated a move into housing. For many, particularly older respondents who had longer prior experience of the ‘freedom’ of travelling, the feeling of confinement was a source of real distress, with sites often referred to as ‘prisons’ or ‘reservations’. The benefits of fresh air attributed to living a nomadic lifestyle in a trailer were not necessarily attributed to living in a trailer on a site:

This metaphorical allusion to fresh air appears closely connected to loss of freedom in general, i.e. to the general lack of autonomy and control over their lives.

Housing

Most respondents spoke of their decision to live in a house as being forced by circumstances rather than as a chosen lifestyle. Several respondents spoke of those they know who could never settle in a house. One explained her reaction after being given temporary housed accommodation when her caravan had been destroyed by fire: ‘Couldn't stick it and begged to leave after one night’ (Bridget aged 33 years living on a site).

A move into housing for health reasons may seem to be beneficial in order to acquire necessary services and facilities, but the psychological impact of giving up a travelling lifestyle and the potential ‘culture shock’ can counteract this perceived benefit. A marked aspect of ‘culture shock’ was often the dislocation from the extended family as most housing can only accommodate the nuclear family. The importance of close extended family in an otherwise hostile world is a major feature of Gypsy Traveller culture: ‘we come from a very big family community love, very big family . . . And we're all very close’ (Mary aged 37 years living on a council site).

The consequent feeling of isolation is a significant cause of distress for many respondents who are no longer able to travel:

One respondent made a comparison with the situation in Ireland where group housing is sometimes available, and this can afford the opportunity for extended families to live close together. This is one alternative that may at least alleviate the isolation factor but seems not to have been explored as a real option in the UK. The same feeling of confinement mentioned by some respondents in relation to living on sites was also relevant to those who are housed. This was particularly highlighted by the behaviour of children who had not previously been used to this confined style of living:

When Gypsies and Travellers are allocated housing they are often subject to racial harassment but a report by the CRE found that much of this goes unreported (Commission for Racial Equality, 2006: 204). Several respondents simply moved away to avoid such intimidation:

Such hostility towards Travellers by virtue of their identity ‘rather than their nomadic lifestyle’ is a further sign of the impact of current Gypsy sites policy on social cohesion. As discussed earlier, the need for security drives Gypsies and Travellers to form tighter enclaves where they and their children can feel protected and where they are not made to feel inferior (Halpern, Reference Halpern2005), thus creating stronger barriers that militate against social cohesion. Lack of social contact was one of the explanatory factors identified in a profile of attitudes to minorities, which found that Gypsies and Travellers were among groups that attracted the most prejudice (Valentine and McDonald, Reference Valentine and McDonald2004).

A wide range of respondents referred to the stress of living in houses. It can reasonably be argued that this reduces the likelihood that the higher incidence of ill health among housed Travellers can be attributed simply to pre-existing health needs forcing a move into housing. The study suggests that a move into housing has a major psychological impact that may also be linked to the higher incidence of anxiety and depression, and possibly other stress-related illnesses. It is most likely that both of these explanations are valid.

Policy response to health inequalities

Although it is common to talk of health inequalities, the term health inequities is more appropriate where the inequalities are unjust and avoidable. In the position paper produced by European Partners for Equity in Health (2006) the following examples of health inequities, are given:

• • health damaging behaviour where the degree of choice of lifestyles is restricted

• • exposure to unhealthy, stressful living and working conditions

• • inadequate access to essential health and other public services

• • health related social mobility. (European Partners FOR equity in Health, 2006: 2)

These wider health determinants are implicated in the health inequities experienced by Gypsies and Travellers as a result of Gypsy sites policy.

In response to Acheson's (1998) recommendation for reduction in health inequalities by effective local partnerships between health, local authorities and other agencies in joint programmes (recommendation 39.1), a health inequalities review was conducted across government departments. A wider policy agenda emphasised a strong focus on local strategic partnerships between the NHS, local authorities and voluntary and community sectors. These partnerships had a remit to set local health inequalities targets and were seen as key to improving social cohesion through neighbourhood renewal (Department of Health, 2001). However the extent to which such partnerships have even been convened, or if so have succeeded in addressing the negative health impact of Gypsy sites policy, has so far appeared negligible. There are paradoxical interpretations of current policies. On the one hand, there are duties under the Local Government Act 2000 to ensure that local authorities prepare strategies to promote economic, social and environmental wellbeing of their area (Stewart, Reference Stewart2005: 532). Yet councils often yield to public campaigns opposing Gypsy site provision, encouraged by media publicity that plays on fears suggesting that this would decrease house values and have a negative effect on the area wellbeing. However councils also have a duty under the Race Relations (Amendment) Act (Great Britain, Reference Britain2000) and should be challenging rather than caving in to such opposition. Current housing policy (Housing Act, 2004) with its obligation on local authorities to carry out accommodation needs assessments appears to be a step forward. However, as Lord Avebury highlighted in a debate in the House of Lords in November 2006:

Many assessments have still to be completed and inflammatory media reports of the initial projections from those assessments that have been conducted, precede any reasoned discussion at council meetings of a planned response to identified needs. This again increases hostility towards Gypsies and Travellers who are resorting to unauthorised encampments.

More recently, since the appointment in 2005 of a lead person for Gypsy and Traveller health in the Equality and Human Rights department in the NHS, there have been attempts to include other Government departments in stakeholder meetings to design policy to improve their health status. Importantly improving Gypsy and Traveller health is one of the four core elements of a new pilot programme to reduce health inequalities, the Pacesetters programme.Footnote ⁷ It is to be hoped that health staff in the pilot sites will also work closely with local Government and the local Gypsy and Traveller communities in meaningful partnership to improve social and environmental conditions by influencing Gypsy sites policies.

Conclusion and implications for future policy

We have seen how Gypsy sites policy, resulting in poor housing environments, constrains Gypsies and Travellers through either forced movement or forced settlement and shapes their beliefs about their perceived lack of worth and status in society. These factors are associated with poor health outcomes.

How could such policies be improved? How can Gypsies and Travellers gain a sense that they are valued as equal citizens in society and thus improve their status and sense of worth? While policy lacks teeth to achieve social justice by meeting their responsibility to provide accommodation according to identified need, councils are likely to continue to avoid the responsibility and give in to high profile campaigns against site provision that increase community tensions and demonise Gypsies and Travellers.

A win/win situation is possible where suitable provision of accommodation not only has the potential to reduce health and social inequalities but could improve social relations. This has been demonstrated by a survey in Scotland where three sites were created despite strong local opposition. Neighbours’ views on the impact of the sites were sought after the sites had been established for a year or more. Most householders who responded reported no specific complaints and acknowledged that their fears resulting in earlier opposition had proved groundless (Duncan, Reference Duncan1996).

Meanwhile, the counterproductive evictions of Gypsies and Travellers from unauthorised sites, in the absence of alternative provision, fuels tensions as new unauthorised encampments become inevitable in more unsuitable locations, thus giving rise to further potential racist hostility. We have seen the effects of racism on health, and, although widely under-reported compared to high profile racist murders among other ethnic minority groups, they can lead to similar crimes of racial hatred towards Gypsies and Travellers (BBC, 2007). Provision of sites per se will be insufficient to build trust and improve social relations. There is also a need for sites to be part of the local communities and not hidden from view by mounds and barriers as some kind of threat and apology. Gypsies and Travellers need to be meaningfully consulted on site design, location, management and the process of determining allocation.

We have seen how a sense of control and a safe secure environment is associated with psycho-social wellbeing. While Gypsies and Travellers lack control to enjoy their basic civil rights of social justice in respect of accommodation and they remain a culture under threat as a result of Gypsy sites policy, they will arguably remain the most health-disadvantaged groups in the UK.