Call for evidence- Public services: lessons from coronavirus




My name is Dr Angelo Ercia and I am currently a research associate for University of Manchester Division of Informatics, Imaging & Data Sciences. I have a Master in public health and practiced as a public health practitioner in the San Francisco Bay Area, California for several years that addressed health disparities and inequalities among ethnic minority, immigrants, and refugee population. I also have a doctorate in Health Policy from University of Edinburgh in which I evaluated the U.S.’s Affordable Care Act and its impact on access to care on low-income populations.


I wanted to submit evidence and share some of my thoughts and experience in hopes that it will be of use to the Parliament when understanding the impact of COVID-19 on inequalities among ethnic minority groups. I hope the information and perspective I provide could also be helpful in developing strategies that aim to address health inequalities due to COVID-19.





The onset of COVID-19 has caused millions of people in the UK to get infected by the virus. People with multiple health conditions particularly with hypertension, diabetes, and cardiovascular disease (CDV), are at a greater risk of being infected with severe cases of COVID-19 (1,2). However, Black, Asian, and minority ethnic (BAME) are particularly vulnerable to getting infected by COVID-19 due to higher rates of being diagnosed with hypertension, diabetes, and CVD (3,4).

              Another important aspect to consider when understanding the unequal impact of COVID-19 particularly on BAMEs is the role of social determinants of health (see Fig 1). Social determinants of health include economic, environmental and social conditions in which BAMEs live, work, learn, play and socialise. For example, a higher proportion of BAMEs experience poverty and deprivation compared to their White counterparts (5). This can be further exacerbated by experiencing structural inequalities and systemic racism when accessing affordable housing, social welfare, and immigration (5). Furthermore, many BAMEs work in the service sector (5). Caribbean and African Blacks, Pakistanis overly represent key workers and 1 in 5 work in health and social care jobs (6). BAMEs are also more likely to live in a multi-generational household that can lead to overcrowding which can make social distancing difficult (5,7). These social determinants have major implications on BAMEs’ health and could significantly increase their risk of getting infected by COVID-19.


                                               Figure1: Social determinants of Health

                                               Source: NHS Scotland (8)



COVID-19’s impact on BAME communities 


The Intensive Care National Audit and Research Centre (ICNARC) first identified the disproportionate impact of COVID-19 on ethnic minority groups in the UK as they suggested that BAMEs experience a higher proportion of being critically ill from COVID-19 (6). Other studies have further supported this claim. Blacks represent 3% of the population but represent 12% of COVID-19 intensive care unit (ICU) patients (9). Findings from Platt and Warwick (2020) also suggest the per capita deaths among the Black Caribbean and Other ethnic group were close to 3 times those of White British. Below is Figure 2 from Platt and Warwick (2020) report that analysed the total registered hospital deaths from COVID-19 in England based on ethnic groups from NHS England data.


Figure 2: Total registered hospital deaths from COVID-19 per 100,000 in England by ethnicity



Source: Graph is directly from Platt and Warwick, 2020

Note: Platt and Warwick, 2020 generated this figure by calculating the population data from 2011 ONS Census of England and Wales with NHS England COVID-19 hospital death figures by ethnicity as of 21 April 2020.



Lockdown impact on inequalities (Were groups with protected characteristics, or people living in areas of deprivation, less able to access the services that they needed during lockdown?)


The implementation of the lockdown in response to COVID-19 may have contributed to the worsening of inequalities experienced by BAMEs. BAMEs have a disproportionate burden of underlying chronic diseases (5). The lockdown has disabled many BAMEs to access healthcare services that are essential to help with managing and treating their health condition. For example, a diabetic BAME patient may have not seen a dietician for weeks. Therefore, they are unable to thoroughly discuss their food intake, receive assistance with meal plans, and review their blood tests. Health education and one-on-one support is an important aspect of managing diabetes (10). The patient may have also experienced limited or no communication with their GP doctor about their diabetes and other health conditions. As a result, this may negatively impact the patient’s overall health and could require more healthcare services in the future.

              Secondly, the lockdown has required many BAMEs to remain in their households that could cause mental health conditions to develop due to anxieties, stress, uncertainties, and experience of unexpected death of family members due to COVID-19. This could cause a rise in various mental health conditions among BAMEs that need extensive and ongoing mental health services.

              Lastly, a large proportion of BAMEs works as frontline workers (6). They are unable to work from home, thus increasing their risk of being infected by COVID-19. They also increase the risk of their household being infected with the virus. This has a major implication if they live in a multi-generational household that includes elders and family members with multiple health conditions. Self-isolation in a crowded household would be extremely difficult and could increase other family members’ risk of being infected by COVID-19.


New pressures placed on public services post COVD-19 (what new pressures will this place on public’s services?)


The following are possible new pressures that could be placed on public services post COVID-19:


  1. The public services may experience significant demand for health care services from BAMEs once isolation is fully lifted due to delayed diagnosis, unmanaged, and untreated chronic health conditions. Therefore, public service capacity may struggle to meet the demand from BAMEs as they will also need to address delayed care from other patients.


  1. The public services may experience an increase in demand to treat more complex health conditions that require surgery or ongoing treatment such as dialysis.


  1. The public services may experience a surge of BAMEs needing mental health services. Mental health conditions that developed during isolation due to stress, anxiety, uncertainties, and death in the family may cause BAMEs to seek more mental health services. It is especially important to consider increasing the capacity of public services to provide culturally appropriate and sensitive mental health services to BAMEs.


Public services effectiveness in identifying the needs of vulnerable groups during COVID-19 outbreak (Have public services been effective in identifying and meeting the needs of vulnerable group’s during COVID-19 outbreak?)


While public services aimed to identify and meet the needs of vulnerable groups during COVID-19 outbreak, there remains room for improvement. The following are recommendations that could improve the effectiveness of public services ability to meet the needs of vulnerable people during an outbreak.


  1. There should be an evaluation of public services messaging to BAME communities during COVID-19. Messaging of COVID-19 to the public has caused some confusion, and; it is essential to understand how this impacted BAME communities. There should also be an emphasis on developing culturally and linguistically appropriate messaging to BAMEs. Studies have found that developing educational materials and messages that are within the appropriate reading level and culturally sensitive are effective in reducing misinformation and misunderstanding (11). Furthermore, public services should consider collaborating with community leaders and organisations that serve a large proportion of BAMEs as they are gateways to the community.


  1. Public services need to increase the collection of disaggregated socio-demographic data (7) on BAMEs. Relying heavily on aggregated ethnic group data in the form of “Other Black” and “Other ethnic group” provides very limited information and does not identify the true impact of COVID-19 on specific groups. Collecting disaggregated data that can help understand the impact of COVID-19 on the Black Caribbean, Pakistani, Bangladeshi, etc., is essential information that can inform targeted messaging and interventions to reduce outbreaks on specific populations. It is also important to consider the role of intersectionality as a person’s ethnicity is just one category that can affect their health outcomes during an outbreak.


  1. Testing and tracing COVID-19 cases is essential particularly among BAME communities. However, public services must consider the locations of COVID-19 testing sites as many ethnic minorities rely on public transport (5). Testing site locations should be placed in areas such as in BAMEs’ neighbourhood to minimize the need to use public transport.










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2.               Sachedina N, Donaldson LJ. Paediatric mortality related to pandemic influenza A H1N1 infection in England: an observational population-based study. Lancet. 2010 Nov 27;376(9755):1846–52.

3.               Khan JM, Beevers DG. Management of hypertension in ethnic minorities. Heart. 2005 Aug;91(8):1105–9.

4.               Schiffrin EL, Flack JM, Ito S, Muntner P, Webb RC. Hypertension and COVID-19. Am J Hypertens. 2020 29;33(5):373–4.

5.               Abuelgasim E, Saw LJ, Shirke M, Zeinah M, Harky A. COVID-19: Unique public health issues facing Black, Asian and minority ethnic communities. Current Problems in Cardiology. 2020 May 8;100621.

6.               Platt L, Warwick R. Are some ethnic groups more vulnerable to COVID-19 than others? [Internet]. [cited 2020 Jun 3]. Available from: https://www.ifs.org.uk/inequality/chapter/are-some-ethnic-groups-more-vulnerable-to-covid-19-than-others/

7.               Haynes Norrisa, Cooper Lisa A., Albert Michelle A. At the Heart of the Matter: Unmasking and Addressing COVID-19’s Toll on Diverse Populations. Circulation [Internet]. [cited 2020 Jun 3];0(0). Available from: https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.048126

8.               NHS Health Scotland. Building our future - NHS Health Scotland’s contribution to public health in Scotland. 2019;52. [cited 2020 Jun 3]. Available from: http://www.healthscotland.scot/media/2744/building-our-future-nhs-health-scotlands-contribution-to-public-health-in-scotland.pdf

9.               Albert M, Chin-Hong P, Haynes N, Alexander K, Cooper L, Ybarra M. At The Heart of the Matter: Unmasking the Invisibility of COVID-19 in Diverse Populations Webinar [Internet]. Association of Black Cardiologists. [cited 2020 Jun 3]. Available from: http://abcardio.org/covid19-webinar/

10.               Burke SD, Sherr D, Lipman RD. Partnering with diabetes educators to improve patient outcomes. Diabetes Metab Syndr Obes. 2014 Feb 12;7:45–53.

11.               Hutchins SS, Fiscella K, Levine RS, Ompad DC, McDonald M. Protection of racial/ethnic minority populations during an influenza pandemic. Am J Public Health. 2009 Oct;99 Suppl 2:S261-270.