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
https://doi.org/10.2105/AJPH.2020.305990
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.
290 Research Peer Reviewed Peek et al.
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mailto:[email protected]
mailto:[email protected]
http://www.ajph.org
https://doi.org/10.2105/AJPH.2020.305990
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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