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Guest article: Daniel La Parra-Casado, Associate Professor, Department of Sociology, University of Alicante, Spain

In the context of this worldwide pandemic, ethnic minority groups in every country, both native and because of immigration processes, have consistently higher rates of hospitalisation and death attributable to COVID-19 than majority ethnic groups in their respective countries. This has been found for the Hispanic, American Indians and Black persons in the United States, for immigrants in Singapore, for people of Black or South Asian ethnicity in Scotland, for people of African descent and indigenous peoples in Latin America (1, 2), and so on. And the same has been described in Europe for the Roma (3, 4, 5, 6, 7, 8).

This constant pattern, for every minority group in every continent, reminds us that ethnicity may play a role as a fundamental cause of health inequity as Link and Phelan suggested. If this is applied to the case of the Roma in Europe, the four essential features of a fundamental cause would be:

1. it influences multiple disease outcomes. In the context of the COVID-19 crisis, a higher number of cases, hospitalizations, and deaths; but also, an increase in other health complications because of the COVID-19 pandemics: mental health, discontinued treatment for chronic conditions, and others;
2. it affects this disease outcomes through multiple risk factors. A series of risk factors could increase the exposure to the virus, like access to tap water (30% of Roma living in households with this basic service), living in overcrowded households, being employed in manual jobs without telework options, lack of good internet access, and so on. But also, the greatest risk of developing critical illness and death because of previous diabetes mellitus, cardiovascular conditions (including hypertension) or respiratory disease, producing a syndemic effect: a synergic effect with existing inequalities in chronic diseases;
3. It determines the access to resources to avoid risks and minimises the consequences of the disease once it occurs. Before vaccines were available, this involved having access to high-quality healthcare, from tests to intensive care units, and not all the Roma population is covered by a healthcare insurance; resources for self-isolation; access to appropriate masks and face coverings; and, now that vaccines are available, it involves being included in vaccination plans with adequate guarantees in terms of availability, accessibility, and acceptability;
4. the association between a fundamental cause and health is reproduced over time via the replacement of intervening mechanisms. In the case of Roma, the impact of the pandemics on educational opportunities (because of school discontinuation, school dropout, and the digital divide to follow distance learning); on their employment because of the overall reduction in the economic activity, but more specifically in the sectors with higher participation of the Roma population -seasonal jobs, unregulated contracts-; increase in the perceived experiences of discrimination related to health-driven stigmatisation processes, scapegoating, and stereotyped narratives in the media.

To sum up, considering ethnicity as a fundamental cause of health inequity highlights the need for policies to address all the issues affecting Roma that have not been tackled in previous years: a general improvement in the living conditions (education, employment, housing, healthcare); effective mechanisms against discrimination; and increased participation of Roma in the decisions that affect their lives, with special attention to specific needs of children, elderly, women, people with disabilities and mobile populations.