PICOT Question Paper

COVID-19 Among African Americans: An Action Plan for Mitigating Disparities Monica E. Peek, MD, MPH, MS, Russell A. Simons, BS, William F. Parker, MD, MS, David A. Ansell, MD, MPH, Selwyn O. Rogers, MD, MPH, and Brownsyne Tucker Edmonds, MD, MPH, MS

As the COVID-19 pandemic has unfolded across the United States, troubling disparities in mortality have

emerged between different racial groups, particularly African Americans and Whites. Media reports, a

growing body of COVID-19-related literature, and long-standing knowledge of structural racism and its

myriad effects on the African American community provide important lenses for understanding and

addressing these disparities.

However, troubling gaps in knowledge remain, as does a need to act. Using the best available evidence,

we present risk- and place-based recommendations for how to effectively address these disparities in the

areas of data collection, COVID-19 exposure and testing, health systems collaboration, human capital

repurposing, and scarce resource allocation.

Our recommendations are supported by an analysis of relevant bioethical principles and public health

practices. Additionally, we provide information on the efforts of Chicago, Illinois’ mayoral Racial Equity Rapid

Response Team to reduce these disparities in a major urban US setting. (Am J Public Health. 2021;111:

286–292. https://doi.org/10.2105/AJPH.2020.305990)

Since April 2020, striking disparities inCOVID-19 mortality between African Americans and Whites have been re-

ported in US cities and states. For ex-

ample, 51% of deaths in South Carolina

have been among African Americans

despite their representing only 30% of

the population.1 In Chicago, Illinois, Af-

rican Americans constituted 70% of

early COVID-19 deaths despite com-

posing only 30% of the population, and

deaths continue to cluster in neighbor-

hoods where more than 90% of the

residents are African American.2

A national analysis of county-level data

confirmed what many scholars pre-

dicted: that place matters in COVID-19

racial disparities. Counties with higher

proportions of African Americans have

higher numbers of COVID-19 cases and

deaths; these counties have more

crowded living conditions and lower

social distancing scores, higher unem-

ployment, lower rates of health

insurance, and higher burdens of

chronic disease.3 Structural racism and

residential segregation have forced a

disproportionate number of African

Americans into low-income neighbor-

hoods that are more physically crowded

and have fewer resources.4 As a result,

social isolation practices can be more

challenging to implement; people must

travel farther for necessary supplies,

often utilizing public transportation, and

return to homes with less personal

space because of multigenerational

living.

Individual risk also matters. Although

not all African Americans live in racially

segregated neighborhoods, all African

Americans, to varying degrees, are af-

fected by economic and sociopolitical

burdens of racism that may increase

their risk for COVID-19 morbidity and

mortality. Structural racism has led to

inequities in education, employment,

income, policing and incarceration,

health care access, chronic stress, and

multiple other factors that affect

health.5,6 For example, African Ameri-

cans are more likely to be employed as

low-wage essential workers, in areas

such as mass transit and airport facili-

ties, food production, and pharmacies.7–9

In New York City, African Americans

constitute 30% of the essential

workforce—more than any other racial

group.10 Those workers, who have kept

critical services operating, have too often

been left without adequate personal

protective equipment.11

Consequently, addressing racial dis-

parities in COVID-19 must use both

place-based and individual risk-based

strategies grounded in public health

practices that utilize data, boost public

health infrastructure, leverage cross-

sector collaboration, and mobilize

community partnerships.

We can draw upon the bioethical

principles of fairness, distributive justice,

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RESEARCH AND ANALYSIS

and reciprocity to provide guidance for

understanding resource allocation and

the sharing of burdens and benefits

across society. Fairness is essential to

building public trust in pandemic-

related processes. Although it is often

thought of as “to each person an equal

share,” it can also be defined as “to each

person according to need.”12 Distribu-

tive justice, as defined by John Rawls,

offers an additional health equity lens by

proposing that institutions, processes,

and structures should be allocated in a

manner that seeks to improve the well-

being of the least advantaged in society,

whose social positions exist because of

limitations placed on their opportuni-

ties.13 Finally, the principle of reciprocity

argues that it is our collective respon-

sibility to ensure that those being placed

in harm’s way are prioritized and

protected.14

Thus, it is the ethical obligation and

civic duty of our governments, hospitals,

and public health agencies to address

COVID-19 racial disparities that our so-

ciety has helped to create. With these

principles in mind, we make the follow-

ing recommendations for policy and

practice. We highlight examples from

the Chicago Racial Equity Rapid Re-

sponse Team formed to address the

city’s COVID-19 disparities (see the

boxes on pages 288 and 289).15 This

discussion is of critical import, not only

for the current crisis but also as we re-

open, rebuild, and reinvest in commu-

nities moving forward.

RECOMMENDATIONS

The following recommendations for re-

ducing COVID-19 disparities among Af-

rican Americans are based in public

health and bioethical principles

designed to promote the health of the

most marginalized populations.

Recommendation #1: Require collection

of race/ethnicity data with COVID-19

reporting. Such data are fundamental

and essential to operationalize dis-

tributive justice. In spite of recom-

mendations set forth by the National

Standards for Culturally and Linguis-

tically Appropriate Services for uni-

versal collection of sociodemographic

data, state-level data on COVID-19

cases, deaths, and testing are missing

for 3, 5, and 46 states, respectively.

For those that have reported, an es-

timated 50% of patients were missing

race/ethnicity data in May 2020.16,17

On May 1, the Centers for Disease

Control and Prevention updated the

COVID-19 reporting form, but race/

ethnicity data are still not required.

Such standards will allow better

tracking of disease burden in different

communities across the United States

and inform just allocation of critical

resources (e.g., remdesivir, ventila-

tors) and infrastructure (e.g., field

hospitals).

Recommendation #2: Utilize risk- and

place-based strategies to decrease

COVID-19 exposure. Reciprocity

demands that essential workers be

outfitted with personal protective

equipment and physical barriers

(e.g., plexiglass partitions) because

of the increased assumed risks as-

sociated with their work. Partner-

ships with community-based

organizations to disseminate re-

sources, such as COVID-19 pre-

vention kits (e.g., soap, gloves, facial

masks, educational materials)

within high-risk communities will be

important. Community policing

practices must not counter these

public health efforts, as evidence

has emerged of racial profiling

among African American men

wearing facial masks.18 Persons

living and working in congregant,

densely populated settings (e.g.,

prisons, skilled nursing facilities)

should have facial masks or cover-

ings. In addition, we recommend

that prison systems identify and

safely release low-risk, nonviolent

offenders, as has been done suc-

cessfully in numerous countries and

US states, to reduce unnecessary

overcrowding that puts the entire

population at risk for COVID-19 in-

fection.19,20

Recommendation #3: Utilize risk- and

place-based strategies to increase

COVID-19 testing. Racial/ethnic mi-

norities have had disparate access

to COVID-19 testing. Recent survey

data suggest that 23% of federally

qualified health centers and similar

community-level care settings, where

African Americans are more likely to

receive care, do not currently offer

drive-through or walk-up testing.21,22

Although many academic medical

centers have developed in-house

tests to increase capacity and de-

crease the wait time for results, Afri-

can Americans have reduced access

to such centers in some areas.23 This

violates the fairness principle. We

must implement universal screening

in high-prevalence areas, based on

epidemiological modeling and hot

spot analyses, with subsequent con-

tact tracing. Drive-through centers

and pop-up clinics in trusted com-

munity spaces (e.g., churches) within

high-risk neighborhoods will be criti-

cal, but insufficient.24 In the short

term, there needs to be a coordinated

investment in and involvement of

public health nurses, community

health workers, and trained civilians to

successfully identify, reach, and test

populations that have been margin-

alized from health care institutions for

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generations.25–28 In the long term,

there needs to be an expansion of the

proportion of underrepresented-in-

medicine minority physicians, who

help create trusted spaces for racial/

ethnic minority patients and dispro-

portionately work to address histori-

cal injustices that have caused many

African Americans to distrust health

care systems. Larger medical centers

will need to share testing resources

with smaller, community-based clinics

and hospitals.

Recommendation #4: Repurpose am-

bulatory staff and infrastructure for

COVID-19 prevention, support, and

monitoring. Chronic diseases such as

diabetes and hypertension, which

disproportionately burden African

Americans, are associated with severe

forms of COVID-19.29–31 Reduced in-

person ambulatory volume creates

opportunities to reorganize human

capital and infrastructure to provide

high-risk patients with enhanced tel-

ehealth monitoring, education, social

risks screening, and supplies to help

manage chronic disease and mitigate

coronavirus risk. Oak Street Health, a

network of outpatient clinics serving

primarily low-income, elderly, minority

patients, has redirected their front

desk and outreach staff to call pa-

tients to screen for social risks (e.g.,

food insecurity) and behavioral health

issues when their offices are virtual

during the pandemic. Their social

work team assesses those who screen

positive, and patient transport vans

are used to deliver food, thermome-

ters, pulse oximeters, medicine, and

other supplies.32

Recommendation #5: Safely isolate and

support COVID-19 patients from high-

risk living conditions. This would in-

volve collaboration between health

care organizations; housing agencies,

hotels, and other housing facilities;

food banks and food distribution

services; mental and behavioral

health services; and other social ser-

vice agencies to facilitate safe social

isolation and support services for

COVID-19–positive, low-income per-

sons living in overcrowded living

conditions. These efforts must be led

by public health campaigns that are

socio-culturally and linguistically ap-

propriate for the intended population,

utilize multimedia dissemination

strategies, and include accurate and

understandable information about

COVID-19 risks, prevention, testing,

contact tracing, treatment, and

recovery.

Recommendation #6: Implement city-

and statewide plans to share re-

sources and patients across hospital

systems. African Americans are more

likely to live in health care deserts

(with no nearby hospital) and more

likely to receive medical care at

resource-limited health care sys-

tems.22,33,34 A landmark study of

Medicare recipients found that 80% of

African Americans received their

health care from 22% of US physi-

cians, and these providers were less

likely to have access to subspecialists

and diagnostic tests.35 Community

hospitals have smaller intensive care

units with fewer ventilators and

trained personnel. Thus, efficient and

Recommendations Illustrative Examples

#1: Require the collection of race/ethnicity data with COVID-19 reporting.

Race/ethnicity data regarding COVID-19 mortality is released daily through city maps showing the neighborhood density of COVID-19 burden.

#2: Utilize risk- and place-based strategies to decrease COVID-19 exposure.

Partner hospitals and health departments work with community-based organizations for distribution of personal protective equipment and food and to conduct contact tracing.

#3: Utilize risk- and place-based strategies to increase COVID-19 testing.

Clients and staff in congregate settings (e.g., homeless shelters, nursing homes, senior buildings) are targeted in high-risk Black and Brown neighborhoods via aggressive testing and contract tracing (30%–40% of Chicago’s COVID-19 mortality is from these settings).

#4: Repurpose ambulatory staff and infrastructure for COVID-19 prevention, support, and monitoring.

Systematic outreach is being conducted to high- risk patients for prevention, social needs, and chronic disease management (with in-home monitoring and medicine delivery) starting with African American and Latinx patients from the highest-risk zip codes.

#5: Use multisector collaboration to facilitate the safe isolation and support of COVID-19 patients from high-risk living conditions.

The city has established a partnership with the Greater Chicago Food Depository to provide additional support for food insecure persons from high-risk zip codes.

#6: Implement city- and statewide plans to share resources and patients across hospital systems.

Regionalization of the treatment of the sickest COVID-19 patients is being accomplished by transfer policies (such as the regionalization of trauma) that allow safety net hospitals to transfer their sickest patients to higher resourced hospitals, often academic medical centers.

#7: Allocate scarce medical resources to reduce racial inequities.

Allocation of remdesivir is based on current and projected hospital caseloads of COVID-19 patients, directing effective medications to hospitals serving the hardest-hit African American and Latinx communities.

Summary Recommendations and Illustrative Examples From the Racial Equity Rapid Response Team of Chicago, Illinois

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data-driven resource sharing not only

advances distributive justice, but can

save lives. Some have suggested

protocols that use zip codes to assign

ventilators and other scarce re-

sources to ensure fair distribution

across communities based on need.36

Having statewide crisis care standards

reduces interhospital variability and

can facilitate dissemination of best-

practice updates from centers of ex-

cellence. Academic medical centers

and large hospital networks have the

ethical obligation to share testing,

personal protective equipment, and

other critical resources with smaller,

less-resourced hospitals to help

maximize patient and employee

safety and health. Finally, all hospitals

should commit to the comprehensive

care of coronavirus patients regard-

less of their ability to pay, and to

transferring patients across health

systems to align patient volume and

acuity with hospital capacity.

Recommendation #7: Allocate scarce

medical resources to reduce racial

inequities. Early in the pandemic, the

possibility that the health care system

would be overwhelmed was very real.

Although the United States has gen-

erally avoided widespread shortages

of critical care resources such as

ventilators, we will soon be faced with

allocation challenges concerning

novel therapies and vaccines.37,38 The

national conversation on the alloca-

tion of scarce health care resources

has focused on developing objective

priority scores, but there are growing

concerns that these algorithms would

be unfair to racial/ethnic minorities,

exacerbate mortality disparities, and

further undermine the African Amer-

ican community’s trust of physi-

cians.39,40 Priority scores that use

chronic diseases as part of their cal-

culations result in the disproportion-

ate assignment of lower scores to

African Americans in 2 distinct ways.

First, these scores may inaccurately

predict mortality risk for African

Americans (because there is variability

in life span associated with different

chronic diseases). Second, systemic

inequities have unfairly disadvantaged

African Americans by increasing their

chronic disease burden, which then

makes them less eligible for life-saving

resources. To date, these points have

been largely underrepresented in the

national conversation. Most plans

published thus far suggest ignoring

race and ethnicity,41,42 but these

proposals clearly will not address the

problem, as severity of illness and

chronic diseases are strongly corre-

lated with race. Although there may

be no single best answer, we must

consider potential options. With fair-

ness, distributive justice, and reci-

procity in mind, we suggest that (1)

predictive models used in scarce re-

source allocation systems be vali-

dated in minority populations (Miller

et al., unpublished data) and (2) ad-

ditional priority be given to persons

from marginalized populations. One

approach has been developed in

Pennsylvania, where individuals from

areas with high area deprivation

The majority of COVID-19–related deaths in Chicago are people of color. Though racial disparity in health care is a historic and ongoing problem in Chicago, the intensity and immediate life-and-death impact of disparity during the COVID-19 crisis calls for an urgent and forceful response from the city. To help save the lives of those most vulnerable and to mitigate effects from the crisis caused by racial disparities, the city mounted the Racial Equity Rapid Response—a data-driven, community-based and community-driven mitigation of COVID-19 illness and death in African American and Latinx Chicago communities.

The goals of this endeavor are to

· Flatten the COVID-19 mortality curve in African American and Latinx communities in Chicago. ·Build a groundwork for future work to address long-standing and systemic inequities in African American and Latinx communities (health, economic, and social). To meet these goals we will need to

· Develop a citywide community mitigation operation that works hyperlocally in partnership with African American and Latinx community organizers and leadership to mitigate COVID-19 illness and death.

· Listen and respond to community-identified needs within the context of partnership that is mutual and centered around benefiting, not burdening, African American and Latinx communities.

· Marshal data, screening tools, testing, and human resources needed to respond to community-identified barriers and needs. The response is organized into 4 categories

· Education: Provide communication and updates that are relevant for residents and speak to realities of their lives. · Prevention: Work to ensure residents have the resources and information needed to protect themselves and their families. · Testing and treatment: Work alongside our health department to ensure the expansion of testing and treatment goes to areas in greatest need and lowers, or eliminates, barriers to access.

· Support services and resources: Work to ensure people have access to supportive services and resources that sustain their livelihoods.

The Racial Equity Rapid Response of the City of Chicago, Illinois

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indices receive additional priority.43,44

This strategy seeks to address the

increased COVID-19 risk (and subse-

quent mortality) created as a primary

consequence of structural racism:

residential segregation and racialized

poverty.45 By considering economic

disadvantage rather than race in

general, this strategy allows a closer

alignment between identifying sub-

groups of high-risk populations

(among racial/minorities) for mitiga-

tion efforts.

SUMMARY AND CONCLUSIONS

Our recommendations for reducing

COVID-19 disparities among African

Americans are based in public health

and bioethical principles designed to

promote the health of the most mar-

ginalized populations. It is our moral

obligation to right these wrongs.

Grounded in bioethical principles of

fairness, distributive justice, and reci-

procity, these recommendations include

required reporting of COVID-19 race/

ethnicity data; strategies to decrease

COVID-19 risk and increase COVID-19

testing; opportunities for health care

systems to repurpose infrastructure to

enhance COVID-19 prevention, support,

and monitoring; strategies for health

care systems to collaborate with other

health care systems, public health

agencies, and community-based orga-

nizations to share data, resources, and

patients; and suggestions to bring racial

equity to scarce resource allocation

protocols.

Our recommendations can reduce

racial disparities in COVID-19 outcomes

and also rebuild trust between African

Americans and the systems designated

to care for them. Sustained and

reciprocal community partnerships,

through community-engaged programs

and community-based participatory re-

search, will be a critical part of this re-

building, especially as we continue

implementing treatments (e.g., remde-

sivir, monoclonal antibodies) and make

plans for population-based COVID-19

vaccination.

It is important to note that this article

has explicitly focused on direct action

recommendations for health care delivery

and public health sectors. For example,

we do not address health insurance and

the need for millions of persons in the

United States to access insurance ex-

changes through the Affordable Care

Act. Nor do we address the disparate

impact that the growing economic

crisis is having on the African American

community and COVID-19 outcomes.

In addition, it is important to recognize

that we focused our attention on Af-

rican Americans, the group for which

the most data currently exist and

whose disparities have been most

highlighted in national discourse. Yet

other marginalized populations—the

Latinx community, low-income per-

sons, immigrants, and others—are also

suffering from COVID-19 disparities

because of structural inequities. Many

of our recommendations may apply to

those populations and communities as

well.

These recommendations require

leadership at the local, state, and federal

levels, and a willingness to engage

in difficult conversations about both

data and race. Indeed, the legacy

of racism remains our nation’s alba-

tross, posing some of the most fun-

damental challenges that we face

as a country. Our response determines

the health and hope not only for our

most vulnerable, but for us all. Ulti-

mately, we will rise or fall as a nation

based on how we empower and take

care of the most marginalized among

us. Chicago and other cities have be-

gun to answer this call. In less than

2 months, the proportion of African

American COVID-19 deaths in Chicago

decreased from 72% to 47% of the

total COVID-19 deaths.46 We can do

this. The choice is ours.

ABOUT THE AUTHORS

Monica E. Peek, Russell A. Simons, William F. Parker, and Selwyn O. Rogers are with the University of Chicago, Chicago, IL. David A. Ansell is with the Department of Medicine, Rush University Medical Center, Chicago. Brownsyne Tucker Edmonds is with the Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis.

CORRESPONDENCE

Correspondence should be sent to Monica E. Peek, MD, MPH, MS, Section of General Internal Medicine, The University of Chicago, 5841 S. Maryland Ave, MC 2007, Chicago, IL 60637 (e-mail: mpeek@medi- cine.bsd.uchicago). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.

PUBLICATION INFORMATION

Full Citation: Peek ME, Simons RA, Parker WF, Ansell DA, Rogers SO, Edmonds BT. COVID-19 among African Americans: an action plan for mitigating disparities. Am J Public Health. 2021;111(2):286–292.

Acceptance Date: September 20, 2020.

DOI: https://doi.org/10.2105/AJPH.2020.305990

CONTRIBUTORS

M. E. Peek and B. Tucker Edmonds performed ar- ticle design, preparation, and editing. R. A. Simons and W. F. Parker performed article preparation and editing. D. A. Ansell and S. O. Rogers performed article editing. All authors made significant intel- lectual contributions.

ACKNOWLEDGMENTS

M. E. P. is supported by the National Institute of Diabetes and Digestive and Kidney Diseases’ Chi- cago Center for Diabetes Translation Research and the Merck Foundation. M. E. P. and B. T. E. have re- ceived grants from the Greenwall Foundation. We thank Bernard Lo, MD, for his thoughtful

review of the article and helpful, constructive feedback.

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CONFLICTS OF INTEREST

The authors have no conflicts of interest to report.

HUMAN PARTICIPANT PROTECTION

This article was exempt from protocol approval because it did not involve human participants or primary data.

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