COVID-19 Among African Americans: An Action Plan for Mitigating Disparities

Abstract

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.

Since April 2020, striking disparities in COVID-19 mortality between African Americans and Whites have been reported in US cities and states. For example, 51% of deaths in South Carolina have been among African Americans despite their representing only 30% of the population.¹ In Chicago, Illinois, African Americans constituted 70% of early COVID-19 deaths despite composing only 30% of the population, and deaths continue to cluster in neighborhoods where more than 90% of the residents are African American.²

A national analysis of county-level data confirmed what many scholars predicted: 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 unemployment, 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 neighborhoods 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 affected 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 Americans are more likely to be employed as low-wage essential workers, in areas such as mass transit and airport facilities, 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 disparities 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, 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 Distributive 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 opportunities.¹³ Finally, the principle of reciprocity argues that it is our collective responsibility 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 society has helped to create. With these principles in mind, we make the following recommendations for policy and practice. We highlight examples from the Chicago Racial Equity Rapid Response 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 reopen, rebuild, and reinvest in communities moving forward.

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.

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.

RECOMMENDATIONS

The following 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 marginalized populations.

Recommendation #1: Require collection of race/ethnicity data with COVID-19 reporting. Such data are fundamental and essential to operationalize distributive justice. In spite of recommendations set forth by the National Standards for Culturally and Linguistically Appropriate Services for universal 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 estimated 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, ventilators) 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 associated with their work. Partnerships with community-based organizations to disseminate resources, such as COVID-19 prevention 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 coverings. In addition, we recommend that prison systems identify and safely release low-risk, nonviolent offenders, as has been done successfully in numerous countries and US states, to reduce unnecessary overcrowding that puts the entire population at risk for COVID-19 infection.^19,20

Recommendation #3: Utilize risk- and place-based strategies to increase COVID-19 testing. Racial/ethnic minorities 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 decrease the wait time for results, African 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 contact tracing. Drive-through centers and pop-up clinics in trusted community spaces (e.g., churches) within high-risk neighborhoods will be critical, 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 marginalized from health care institutions for 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 disproportionately work to address historical 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 ambulatory 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 telehealth 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 patients 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, thermometers, pulse oximeters, medicine, and other supplies.³²

Recommendation #5: Safely isolate and support COVID-19 patients from high-risk living conditions. This would involve 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 service agencies to facilitate safe social isolation and support services for COVID-19–positive, low-income persons living in overcrowded living conditions. These efforts must be led by public health campaigns that are socio-culturally and linguistically appropriate 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 resources 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 systems.^22,33,34 A landmark study of Medicare recipients found that 80% of African Americans received their health care from 22% of US physicians, 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 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 resources 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 excellence. 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 regardless 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 generally 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 allocation 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 American community’s trust of physicians.^39,40 Priority scores that use chronic diseases as part of their calculations result in the disproportionate 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 correlated with race. Although there may be no single best answer, we must consider potential options. With fairness, distributive justice, and reciprocity in mind, we suggest that (1) predictive models used in scarce resource allocation systems be validated in minority populations (Miller et al., unpublished data) and (2) additional priority be given to persons from marginalized populations. One approach has been developed in Pennsylvania, where individuals from areas with high area deprivation indices receive additional priority.^43,44 This strategy seeks to address the increased COVID-19 risk (and subsequent 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 subgroups of high-risk populations (among racial/minorities) for mitigation 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 marginalized populations. It is our moral obligation to right these wrongs. Grounded in bioethical principles of fairness, distributive justice, and reciprocity, 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 organizations 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 research, will be a critical part of this rebuilding, especially as we continue implementing treatments (e.g., remdesivir, 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 exchanges 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 African 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 persons, 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 albatross, posing some of the most fundamental challenges that we face as a country. Our response determines the health and hope not only for our most vulnerable, but for us all. Ultimately, 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 begun 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.