key: cord-271440-qiwixpai authors: ribeiro, helena; lima, viviana mendes; waldman, eliseu alves title: in the covid-19 pandemic in brazil, do brown lives matter? date: 2020-07-02 journal: lancet glob health doi: 10.1016/s2214-109x(20)30314-4 sha: doc_id: 271440 cord_uid: qiwixpai nan in the lancet global health, a pioneering study by pedro baqui and colleagues 1 confirms in brazil findings observed in other countries hit hard by covid-19: that mortality rates from the pandemic differ by geographical region and ethnicity, with disproportionate impact for black populations and other ethnic minorities. 2, 3 we can discuss these findings in the context of the social protests occurring in the past few months against structural racism and to the slogan "black lives matter". however, in this comment, we go beyond ethnicity, focusing on social and environmental determinants of health for about 50% of brazilians. using covid-19 hospital mortality data from sivep-gripe (sistema de informação de vigilância epidemiológica da gripe) dataset, baqui and colleagues did a cross-sectional observational study to assess regional variations in patients with covid-19 admitted to hospital by state and by two socioeconomically grouped regions (north and central-south). the ethnicity of patients was categorised according to the five categories used by the brazilian institute of geography and statistics: branco (white), preto (black), amarelo (east asian), indígeno (indigenous), or pardo (mixed ethnicity). the authors used mixed-effects cox regression survival analysis to estimate the effects of ethnicity and comorbidity at an individual level in the context of regional variation. baqui and colleagues found that, compared with white brazilians, pardo and black brazilians who were hospitalised had significantly higher mortality risk (hazard ratio 1·45, 95% ci 1·33-1·58 for pardo brazilians; 1·32, 1·15-1·52 for black brazilians). pardo ethnicity was the second most important risk factor after age for death. the authors also showed that, in the north region, hospitalised patients had higher risk of death from covid-19 than those in the central-south region. rio de janeiro was an outlier, with mortality rates similar to those of northern states. we add to their findings that incidence rates were also higher in northern regions. 4 speculation that severe acute respiratory syndrome coronavirus 2 would have milder transmission in low latitudes has delayed actions in northern regions. however, historically, these areas face several challenges that directly affect their capacity to respond to the covid-19 pandemic: shortages of doctors and intensivists; fragile epidemiological surveillance; poorer network of health services than in other regions; and fewer family health teams, hospital beds, and number of intensive care units (icus) per inhabitant than in other regions. therefore, discussions regarding ethnicity and regional variations must be integrated, not only because northern states and rio de janeiro have higher proportions of pardo and black populations, but also because the root causes of higher mortality are overlapping. the percentage of low-income families living in subnormal housing, with higher average numbers of individuals per room, is more elevated in northern areas than in the centralsouth region and higher among pardo and black families than in white families. these conditions favour intense circulation of respiratory pathogens. low-income neighbourhoods also have higher population density and low adherence to social distance measures. in these often hot and crowded neighbourhoods, the streets and sidewalks have cultural importance and become part of the living space. additionally, lower schooling in northern regions and among pardo and black populations might jeopardise the comprehension of risks and measures proposed by sanitary authorities, as well as judgment of the right time to seek medical assistance. additionally, in the north region, lower percentages of the urban population are served by piped water compared with those of other regions (69·5% in the north, 88·7% in the northeast, and 96% in southern regions). 5 this situation means that a substantial proportion of the northern urban population has difficulty in adhering to the simplest prevention recommendation of hygiene, such as washing hands. the prevalence of comorbidities among pardo and black populations in brazil is higher than among other ethnicities, including overweight and obesity, 6 risk factors for severity of symptoms of covid-19. [2] [3] [4] hypovitaminosis d is also more prevalent among pardo and black people in brazil than among other ethnicities. 7 the lower the level of schooling, the higher the chances of obesity in brazilian women. 6 with soaring numbers of cases, cities in the northern region faced collapse of their health system, with worst cases occurring in manaus, fortaleza, and natal. however, we note that phases of the epidemic vary within the country, and the northern region has probably reached the peak of the first wave of transmissions, whereas this might not be the case for other regions. the situation is dynamic, and baqui and colleagues' research portrays a snapshot in a timeline. additionally, substantial under-reporting of deaths and cases of covid-19 is occurring, related to low testing. this under-reporting is more intense in the northern region, which might reinforce health inequities. we draw attention to issues of mobility and historical shortages of doctors in villages and poverty areas, which are not discussed in baqui and colleagues' study. in the amazon, most people move around by boat through igarapés and rivers, and trips to cities with health equipment and medical doctors might take hours or even days. in rio de janeiro, mobility plays a role too. the poor, mostly pardo and black, live in shantytowns on steep slopes with no streets or health services, where ambulance access is difficult; or in suburbs with precarious and very crowded public transportation, facilitating transmission. in those cases, the delay to hospital admission might be fatal. additionally, this population works mainly in unstable jobs with no payment for sick days, and thus are likely to postpone going to health services until disease symptoms are acute. most doctors are white and might show less empathy for pardo and black patients. by contrast, the majority of non-medical health staff is composed of pardo and black people, who are more exposed to covid-19 risks, as pointed out by baqui and colleagues, sometimes without adequate protection equipment and tests to identify early contagion. in rio de janeiro, but not exclusively, hospital equipment, beds, and icus were poorly managed, which left many people to die in inadequate places or at home. irresponsibility and corruption have also played a role in this context. therefore, there are people for whom and places where vulnerability and susceptibility 8 act together to exacerbate the risks of covid-19, and this is compounded by a resistance of the ministry of health to account for ethnicity in its approach to the pandemic. shedding light on these issues is a merit of baqui and colleagues' study. we declare no competing interests. we thank the brazilian national council for scientific and technological development for a productivity grant for hr and postdoc scholarship for vml. ethnic and regional variations in hospital mortality from covid-19 in brazil: a cross-sectional observational study ethnic disparities in covid-19 mortality: are co-morbidities to blame? hospitalization and mortality among black patients and white patients with covid-19 boletim epidemiológico especial. doença pelo coronavírus covid19 sistema nacional de informações sobre saneamento prevalence of obesity and associated factors in the brazilian population: a study of data from the 2013 national health survey does vitamin d play a role in the management of covid-19 pandemic in brazil? differential vulnerability and susceptibility: how to make use of recent development in our understanding of mediation and interaction to tackle health inequalities key: cord-255064-u95pxed7 authors: taylor, kishana title: msphere of influence: that’s racist—covid-19, biological determinism, and the limits of hypotheses date: 2020-09-30 journal: msphere doi: 10.1128/msphere.00945-20 sha: doc_id: 255064 cord_uid: u95pxed7 kishana taylor works in the field of virology. in this msphere of influence article, she reflects on the personal impact of “racial health disparities and covid-19 – caution and context” by merlin chowkwanyun and adolph l. reed, jr. (n engl j med 383:201–203, 2020, https://doi.org/10.1056/nejmp2012910) and “a hypothesis is a liability” by itai yanai and martin lercher (genome biol 21:231, 2020, https://doi.org/10.1186/s13059-020-02133-w) and how it became part of the mission for black in microbiology week. b lack in microbiology week was created following the latest in a series of police killings-ahmaud arbury, george floyd, and breonna taylor, among others-that created an atmosphere where our contemporaries and superiors were willing to have open and honest conversations about the experiences of black people in stem (science, technology, engineering, and mathematics). like the many black in stem discipline movements on twitter recently (e.g., black in neuro and black in botany), we wanted to connect and celebrate black microbiologists. given that these moments also occurred during the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) pandemic, we considered this an opportunity to highlight the coronavirus disease 2019 (covid-19) disparities observed in black, native, and other communities of color compared to white communities. for these reasons, we established the mission of black in microbiology week as the following: • showcase the presence and accomplishments of black microbiologists from around the globe. • connect black microbiologists with one another and foster a sense of community among them. • provide a forum to discuss racial disparities in microbiology and its subdisciplines. • amplify black scientists in all disciplines, acknowledge the contributions to their disciplines, and support the collective work of pursuing equity in academia, industry, government, and beyond. a recent paper in genome biology (1) described the flaws of hypothesis-driven science including how it often leads to scientists missing novel discoveries and stifled creativity. i argue that hypothesis-driven data are flawed in additional ways, especially when it comes to infectious disease microbiology and health disparities research. as scientists, we seek to have neutral hypotheses. in other words, hypotheses are supposed to be free of bias and based solely on the data. for the sake of this commentary, i define bias as preconceived notions or experiences that can influence our interpretation of data. however, this aim is flawed, as even the way we think, the way we interpret data, is influenced by our experiences through life. oftentimes, as microbiologists, our hypotheses and experiments are informed by data, and often our biases, but not the context or history behind the data or the biases. it can be easy to dismiss the contributing context as a different discipline, but this context should inform how we conduct our research and examine our hypotheses before we even begin data collection. the field of epigenetics has taught us that on a genetic scale, humans of all races are genetically similar (2) . we also know that the environment can greatly influence what, when, and how genes are activated. from a perspective that does not consider the social determinants of health on a macroscale, it may seem that race is the underlying factor between differences in disease rates. but examining the context of the data and the racial categories shows that racism (i.e., how an individual categorized into a racial group is treated), and not race, is the cause. institutional and structural racism, racism that is embedded into the normal day to day practice and underpinnings of society, determines the access a person has to different environments, as well as how that person is treated in day to day interactions. so when we see data that say black people have higher rates of covid-19, we have to first consider what role institutional and structural racism have in shaping the environments in which they live and work. a recent perspective published in the new england journal of medicine, written by dr. merlin chowkwanyun and dr. adolph l. reed, jr. (3) cautioned against the slippery slope of observing racial disparities in the rates of covid-19 cases and deaths and then relating them to biological determinism. dr. chowkwanyun and dr. reed advocate for examining the disparity data with the "explanatory context in order to avoid perpetuating harmful myths and misunderstanding that actually undermine the goal of eliminating health inequities." this is an important point to make, as many hypotheses have already attempted to blame biological differences between racial groups to explain the disparities away. examples include vitamin d deficiency, poor diets, and differential expression of the enzyme tmprss2, among others. the problem with immediately trying to find a biologic cause for health disparities is that it ignores the social aspects of disease, also known as the social determinants of health (sdoh). sdoh, as defined by the cdc, are "conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of-life risks and outcomes (4) ." factors contributing to disease that could be considered a sdoh include access to health care and quality of the care. with black in microbiology week, we want to bring awareness to how the surface level analysis of infectious disease health disparities data often leads to racist hypotheses. ignoring the effects of institutional and personal racism on black people's access to health, wealth, or their ability to physically distance, we perpetuate racism and gaslight an entire community of people. black microbiologists are often the only black person in their lab or even department, making it tenuous, especially as early career researchers, to communicate this limitation to our colleagues and superiors. the black in microbiology committee wants to create a *safe* platform to discuss these flawed and racist hypotheses that other microbiologists can attend to understand our experiences and perspectives. we hope that our scientific colleagues can implement these antiracist concepts in their own labs and departments to further change the culture of scientific inquiry to effect greater change in our communities. for microbiologists to do better, they need to: (i) ask themselves the purpose that their hypotheses serve, (ii) interrogate their own biases before forming a hypothesis, and (iii) consider alternative explanations for health disparities that include racism and sdoh. to continue to learn, hear from, and amplify black microbiologists, consider following black in microbiology week (28 september to 4 october 2020) with the #blackinmicro hashtag and visiting the website blackinmicrobiology.org. a hypothesis is a liability race and the clinic: good science? human genome findings practically erase race as a biological factor racial health disparities and covid-19 -caution and context social determinants of health: know what affects health. centers for disease control and prevention key: cord-304966-w2voi8en authors: cummings, cori; almallouhi, eyad; al kasab, sami; spiotta, alejandro m.; holmstedt, christine a. title: blacks are less likely to present with strokes during the covid-19 pandemic: observations from the buckle of the stroke belt date: 2020-08-17 journal: stroke doi: 10.1161/strokeaha.120.031121 sha: doc_id: 304966 cord_uid: w2voi8en the impact of the coronavirus disease 2019 (covid-19) pandemic on stroke systems has not been systematically evaluated. our study aims to investigate trends in telestroke consults during the pandemic. methods: we did retrospective chart review of consecutive patients seen through a telestroke network in south carolina from march 2019 to april 2020. we dichotomized patients to precovid-19 pandemic (march 2019 to february 2020) and during covid-19 pandemic (march to april 2020). results: a total of 5852 patients were evaluated during the study period, 613 (10.5%) were seen during the pandemic. the median number of weekly consults dropped from 112 to 77 during the pandemic, p=0.002. there was no difference in baseline features; however, black patients were less likely to present with strokes during the pandemic (13.9% versus 29%, p≤0.002). conclusions: the covid-19 pandemic has led to a significant drop in telestroke volume. the impact seems to disproportionately affect black patients. t he novel coronavirus disease 2019 (covid-19) has rapidly spread since initial report in december 2019 to involve >200 countries, with over 300 000 deaths worldwide. 1 while the hallmark of covid-19 is respiratory insufficiency, up to 36% of patients with covid-19 have neurological manifestations and ≈6% present with cerebrovascular diseases. 2 despite concern for increased risk of stroke, many centers reported a significant decline in number of patients presenting with strokes during the pandemic. [3] [4] [5] this alarming drop raised concern that patients with stroke may be reluctant to seek medical care in the setting of the pandemic. 6 such abundance of caution has the potential to cause overall worse outcomes for those not presenting to a hospital for their health concerns, especially in acute stroke. 7, 8 furthermore, recent studies have suggested a stronger impact of covid-19 in black patients, with 3-fold incidence in predominantly black counties, and mortality rates rising to up to almost 6× those of white patients in some inner cities. 9,10 with the higher risk seen in black patients, concern arises that this fear of seeking care for acute medical problems, such as stroke, may disproportionately affect black patients. the medical university of south carolina is the hub for a large video-based telestroke network covering >38 hospitals throughout south carolina. 11 we sought to evaluate change in the volume of telestroke consults during covid-19 pandemic. in addition, we sought to assess for racial disparities created by the pandemic. the data that support the findings of this study are available from the corresponding author upon reasonable request. we performed a retrospective review of the prospectively maintained telestroke registry at medical university of south carolina between march 2019 and april 2020. in this analysis, we included 27 centers that were in the telestroke network for the study duration. collected data included baseline demographics, time from symptom-onset to presentation, baseline national institutes of health stroke scale, tpa (tissue-type plasminogen activator) administration, mechanical thrombectomy, door to needle time, and door in door out for transferred patients. discharge outcomes included in-hospital mortality, national institutes of health stroke scale on discharge, and modified rankin scale on discharge. patients were grouped by month during which consult occurred and then further grouped into those occurring before covid-19 pandemic (march 1, 2019 to february 29, 2020) and during the pandemic (march 1, 2020 to april 30, 2020). descriptive statistics were done using mann-whitney u test for continuous variables, and χ 2 (or fisher exact test for cells <5) for categorical variables. alphalevel was set to 0.05 for significance, and all reported p values are 2-sided. data analysis was done using spss version 25 (ibm, il). authors confirm that the study is an observational minimal risk study, and no consent is required per our institutional policy. our study was approved by the institutional review board at our institution. total of 5852 patients were evaluated in the telestroke network during the study period, of those, 5239 (89.5%) during the year preceeding the pandemic. the weekly number of patients presenting with stroke was lower during the pandemic (77 [interquartile range [iqr] , 69-84] versus 112 [iqr, 102-120] before the pandemic, p=0.002) ( figure 1 ). figure i in the data supplement shows the number of patients with stroke presenting directly to the thrombectomy-capable stroke center during the same time period. in addition, there was lower percentage of black patients presenting during the pandemic (13.9% versus 29% before, p<0.001). the table summarizes table i in the data supplement who presented during covid-19 pandemic and those who presented during the same time of the year (march and april) of 2019. as summarized in table ii we evaluated the volume and outcomes of telestroke patients presenting during covid-19 pandemic compared with patients presenting during the year prior. our study shows an overall drop in the number of telestroke consults during the pandemic. importantly, there was a disproportionately lower percentage of black patients presenting during the pandemic. other studies have reported a decline in stroke presentations throughout the united states and the world during the covid-19 pandemic. 4, 5 our findings corroborate prior studies reporting falling stroke volume. however, our study is unique because it presents patient-level data in an area of high stroke rate and significant racial disparity. 12, 13 interestingly, unlike previous studies, our study shows higher percentage of patients received tpa, without delay in treatment, and that similar percentages of patients received mechanical thrombectomy. one possible explanation to the higher rate of thrombolysis is that, while not statistically significant, there was a trend for shorter symptom-onset to hospital arrival time during covid-19 pandemic by about 15 minutes which could be clinically significant. an important finding in our study is that a lower percentage of black patients presented with strokes during the pandemic. this finding is alarming, as many studies have highlighted existing racial disparities in stroke care, with black patients having both higher risk factors as well as higher in-hospital mortality and burden of stroke disability. 14 black patients are also suffering from a higher incidence of covid-19 infection, as well as an increased mortality rate. 9, 10 in this climate, black patients may experience a stronger pull to avoid medical care, due to this harsh reality that their risk from covid-19 is inherently higher than that facing other races. more concerning is the fact that the decline in number of black patients presenting with stroke was not associated with an increased stroke severity in patients who presented, which might indicate that even patients with severe strokes did not present to emergency rooms for evaluation. if not addressed, this reluctance in seeking care may worsen the existing disparity in stroke outcome. limitations of our study include its retrospective nature and the uncertainty whether the decrease of patients with stroke presenting reflects a true decline in stroke rate as opposed to patients' fear of presenting to medical facilities to avoid exposure to covid-19. however, stroke rate is less likely to be affected by covid-19 pandemic in south carolina given the small number of cases (table i in data supplement), 15 and there is no strong data suggesting seasonal variation in stroke rate. another limitation that we do not have the number of patients who had large artery occlusion which makes it difficult to know whether covid-19 pandemic caused a higher rate of occlusions. however, we were able to show a stable rate of mts performed during the pandemic. there is a decrease in number of patients presenting with strokes during covid-19 pandemic, which could be secondary to patients' fear of exposure to covid-19 in healthcare facilities. this concern is more alarming in black patients. these results exemplify the crucial need for continued public health education about the importance of immediate stroke care. covid-19 dashboard by the center for systems science and engineering neurologic manifestations of hospitalized patients with coronavirus disease 2019 in wuhan, china are stroke sufferers silent victims of covid-19? https:// utswmed.org/medblog/covid19-stroke-volume-decrease falling stroke rates during covid-19 pandemic at a comprehensive stroke center collateral effect of covid-19 on stroke evaluation in the united states amid pandemic, public wary of seeking non-coronavirus care from providers stroke thrombolysis trialists' collaborative group. effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct covid-19 and african americans chicago's coronavirus disparity: black chicagoans are dying at nearly six times the rate of white residents, data show long-term functional outcome of telestroke patients treated under drip-and-stay paradigm compared with patients treated in a comprehensive stroke center: a single center experience exploring the spatial patterning in racial differences in cardiovascular health between blacks and whites across the united states: the regards study racial/ethnic disparities in acute ischemic stroke treatment within a telestroke network american heart association stroke council; council on cardiovascular nursing; council on epidemiology and prevention; council on quality of care and outcomes research. racial-ethnic disparities in stroke care: the american experience: a statement for healthcare professionals from the american heart association/american stroke association key: cord-023989-d6c1is5s authors: williams, richard allen title: conclusion and afterword date: 2020-04-25 journal: blacks in medicine doi: 10.1007/978-3-030-41960-8_10 sha: doc_id: 23989 cord_uid: d6c1is5s the previous chapters contain a great deal of medical, socioeconomic, demographic, epidemiologic, racial, ethnic, educational, and cultural information pertaining particularly to the black population of the united states, but it is admittedly somewhat incomplete. there is so much more that might have been included, but space and time limitations preclude a more comprehensive coverage of everything that touches upon the healthcare scene involving black americans. in this brief postscript, i would like to suggest to the reader to consider a few more important issues affecting black health. the book that you have just read contains a great deal of medical, socioeconomic, demographic, epidemiologic, racial, ethnic, educational, and cultural information pertaining particularly to the black population of the united states, but it is admittedly somewhat incomplete. there is so much more that might have been included, but space and time limitations preclude a more comprehensive coverage of everything that touches upon the healthcare scene involving black americans. in this brief postscript, i would like to suggest to the reader to consider a few more important issues affecting black health. the problem of insufficient recruitment of african american students into careers in medicine is often referred to as the medical school "pipeline" problem, which has been highlighted by several incisive publications such as an american crisis: the growing absence of black men in medicine and science, a book whose lead author was cato t. laurencin, md, phd, rapporteur for the national academies of sciences, engineering, and medicine [1] . in the proceedings of a joint workshop in which several prominent luminaries participated, it was pointed out that blacks, and black men in particular, are underrepresented among medical school applicants ( fig. 10 .1) [2] . as louis sullivan, md, chairman and ceo of the sullivan alliance to transform the health professions, noted in his keynote speech, although african americans constitute 13% of the us population, they constitute only 7% of medical students and less than 3% of practicing doctors. in addition, we seem to be reversing course regarding the admission of black men to medical school; in 1978, 542 black males matriculated in medical schools compared to 515 blacks in 2014 ( fig. 10 .2) [2] . thus, the pipeline has grown narrower, with insufficient numbers of black doctors eventually being produced. this has ramifications for the black community, since it has been shown that black patients elect to receive more preventive care when the providers are black as compared to when they are not [3] . in addition, physicians who are members of underrepresented groups are more likely than whites to serve poor, minority, and medicaid populations [4] . there is also a need for more diversity in leadership positions in academic medicine. as stated by cantor et al., "diversity improves patient care….promoting women and underrepresented minorities to leadership positions may well enable academic medicine to better serve our diverse population" [5] . only 2% of full-time medical school faculty consists of black men, according to the association of american medical colleges (aamc). violence in the black community is a problem that has flown under the radar until recently, when the national medical association (nma) created a task force to address it. the nma's working group on gun violence and police use of force, of which i was a member, was led by national co-chairs roger a. mitchell, jr., md, chief medical examiner for the district of columbia, and [2] ; graphic courtesy of the national academy of medicine https://nam. edu/an-american-crisis-the-lack-of-black-men-in-medicine/) eva louise frazer, md, an internist and prominent community activist from st. louis, missouri [6] . following an initial white paper on the subject, a fullscale article was published and disseminated in 2018 [7] . the report detailed the police use of excessive force, and many approaches to reducing the level of violence were suggested, including greater involvement by the community of black physicians who must play a vital role in eradicating this epidemic. more interaction between the police, physicians, and the public was recommended. the nma has begun discussions with the national organization of black law enforcement executives (noble; https://noblenational.org/) on the issue of violence and the police use of force in the black community. this dialogue has been facilitated by former norfolk, virginia, chief of police and former noble president john i. dixon iii and sheila l. thorne, president and ceo of the multicultural healthcare marketing group, who have collaborated with the nma and other medical groups in communities of color to develop strategies to combat this problem, which is spreading explosively throughout the country. recently, there has been speculation that exposure to violence has had psychopathological fallout in the black community with the development of post-traumatic stress disorder (ptsd), which is defined as a trauma-or stress-related reaction that may develop in individuals following exposure to an ordeal or an event in which death or physical harm has occurred, is witnessed, or is threatened. this is another example of the public health consequences of violence and police brutality in the black community, leading to a population that may be in need of psychotherapy. it is often said that being black in america exposes one of necessity to mental illness on a personal, familial, or community level. mental health issues in the black community have been largely ignored or swept under the carpet. we must bring greater recognition to this problem in order to treat it. according to the us department of health and human services, african americans are 20% more likely than whites to report that they have severe psychological stress [8] . however, many blacks do not present themselves for psychiatric attention because they have a fear of being stigmatized; studies have shown that african americans view mental illness as highly stigmatizing, resulting in low treatment-seeking [9] . in addition, they fear the criminalization of mental illness, according to patrisse cullors of black lives matter [10] . tied to this is the sudden increase in suicide attempts by young black males, which has been chronicled in a special story by cnn [11] , based on a cdc study that was recently released, containing data from 1991 to 2017. this is a prime area for more research and prevention of a serious health problem in the black community. hopefully, organizations like the trevor project, which provides crisis intervention and suicide prevention services primarily to lgbtq/q young people, will become more involved in the special situation facing black youth, who are more impacted by poverty, low income, joblessness, racism, and homelessness. high maternal mortality is a problem that the black community has silently dealt with for decades. it has several definitions. one definition is death of a woman while pregnant or within 42 days of end of pregnancy, irrespective of the cause of death. defined as the number of maternal or pregnancy-related deaths in a given time period per 100,000 live births during the same period, the maternal mortality rate has been rising for american women in general but much more so for black women, who experience more than three times the rate that white women do. in fact, as fig. 10.3 shows, the statistics for black women in the united states are closer to women from brazil, uzbekistan, malaysia, and mexico compared to non-hispanic american white women whose statistical profile resembles that of women in more affluent countries such as japan, new zealand, the united kingdom, and france [12] . there is also a difference in causation of pregnancy-related deaths between blacks and whites, as reported by a study of maternal mortality review committee data by the building us capacity to review and prevent maternal deaths initiative, a partnership of the association of maternal and child health programs (amchp), the centers for disease control and prevention (cdc) division of reproductive health, and cdc foundation (fig. 10.4 ) [13] . the main causes in blacks are cardiomyopathy, preeclampsia, and eclampsia, whereas the principal causes in whites are cardiovascular and coronary conditions, hemorrhage, mental health conditions, and infections. members of the congressional black caucus, and senator kamala harris in particular, have expressed grave concern about these disparities in maternal mortality. senator harris says that racial bias is part of the cause. senator elizabeth warren agrees. one area of focus is on prevention; it is estimated that about twothirds of black maternal deaths are entirely preventable if more attention is paid to socioeconomic determinants of health by eliminating social inequities through the provision of clean drinking water, better housing, improved transportation, and greater access to high-standard healthcare facilities for pre-and postnatal care. however, it should also be recognized that higher mortality in black women transcends social class to some extent in that those who are more affluent and better educated are also exposed to the risk, such as in the case of black tennis star serena williams, who almost died from a complication of pregnancy. obviously, more research is needed in this area. the march of dimes is one agency that is focusing on this problem, and congresswomen alma adams (d-nc) and lauren underwood (d-il) have launched the black maternal health caucus to improve outcomes in this problem area. it seeks to raise awareness of the condition in the us congress so that black maternal health becomes established as a national priority. they are interested in hearing from constituents from throughout the country. they may be reached at their office at 2436 rayburn house office building, washington, dc, 20515-3312 or by calling their office at 202-225-1510. we have much work to do to make an impact on the factors causing disparities in healthcare delivery and to protect the lives of all citizens of the united states, and especially of those who are the most vulnerable, such as the black population and other people of color. it is my hope that one day it will be unnecessary to make efforts like this on behalf of discrete segments of our society, because we will all truly be equal. the poem common dust by black poet georgia douglas johnson expresses that hope: and who shall separate the dust. what later we shall be: whose keen discerning eye will scan. and solve the mystery? the high, the low, the rich, the poor, the black, the white, the red, and all the chromatique between, of whom shall it be said: here trusty, rachel turner, jasira ziglar). "we are our ancestors' wildest dreams," student russell j. ledet wrote in a tweet sharing a photograph of the moment (fig. 10.5) . thus, our saga of blacks in medicine has come full circle, from the shackles of slavery to the halls of sophisticated medical schools, and back, to revisit the place where so much suffering occurred. we can thank those students for providing the connection between the brutal past and the bright future that awaits them. also, as this book was about to go to press, the coronavirus (covid-19) pandemic erupted and is still largely uncontrolled at the time of this writing. although it is not possible to review all aspects of this crisis in this small space, it is important to mention some relevant issues regarding the disproportionate impact that this disease is having on communities of color in the united states. early data indicates that the occurrence rate and the death rate are disproportionately high in large cities even where african americans are not the majority of the population. for instance, according to cnn host and journalist van jones, who spoke on cnn on april 6, 2020 in an opinion piece titled "black america must wake up to this viral threat", in milwaukee county, wisconsin, where 27 percent of the residents are black, almost half of those infected with the virus are black, and 81 percent of those who died of covid-19 are african american. in illinois, where blacks make up only 14.6 percent of the population, 28 percent of those affected are black. in michigan, including detroit, blacks account for 33 percent of the cases and 40 percent of the deaths. and in louisiana, where blacks are not in the majority, governor john bel edwards has indicated that almost 70 percent of the deaths are in black people. why is this happening? one might speculate that the co-morbidities that predominate in black communities such as high rates of heart disease, hypertension, diabetes, asthma, cancer, and other disorders, combined with a high incidence of the socioeconomic determinants of health make the black population particularly vulnerable to covid-19 infection. all of the data have not been gathered because very few cities and states are tracking the incidence and deaths by race and ethnicity, which is necessary to draw a clear picture of what is going on. without that data, resources and funding such as money from the recently passed $2 trillion dollar stimulus bill may not be appropriately distributed to those in poor communities of color where the need for relief seems to be the greatest. and more information and data should be demanded from the centers for disease control and prevention (cdc) which so far has been reluctant to release anything to the public, despite requests made by some congressmen including senator wyden of oregon. we can and must do more to avert unnecessary deaths and suffering from this deadly scourge. blacks, including african american organizations, must come to the rescue of themselves before it is too late. an american crisis: the growing absence of black men in medicine and science an american crisis: the lack of black men in medicine does diversity matter for health? experimental evidence from oakland physician service to the underserved: implications for affirmative action in medical education unplugging the pipeline -a call for term limits in academic medicine national medical association seeks to address violence in the african american community. philadelphia tribune the violence epidemic in the african american community: a call by the national medical association for comprehensive reform issues/black-african-american-communities-and-mental-health. accessed african american men and women's attitude toward mental illness, perceptions of stigma, and preferred coping behaviors black lives matter's patrice cullors on the criminalization of mental illness suicide attempts by black teens are increasing, study says america is failing its black mothers. harvard public health report from nine maternal mortality review committees key: cord-348848-js36pw2r authors: filut, amarette; carnes, molly title: will losing black physicians be a consequence of the covid-19 pandemic? date: 2020-07-28 journal: acad med doi: 10.1097/acm.0000000000003651 sha: doc_id: 348848 cord_uid: js36pw2r a compelling case exists that increasing the number of black physicians trained and practicing in the united states is one effective intervention to promote health equity and reduce the persistent health disparities that have become glaringly evident during the covid-19 pandemic. however, the u.s. physician workforce has relatively few black physicians. blacks comprise approximately 13% of the u.s. population but only 5% of practicing physicians. in this invited commentary, the authors caution that the covid-19 pandemic may erode the meager progress that has been made in increasing the number of black physicians. this loss of black physicians may happen because black patients are overrepresented among cases of covid-19, black physicians care for relatively more black patients often in settings with less access to sars-cov-2 testing and personal protective equipment, and black physicians have more comorbid chronic conditions that increase their own susceptibility to mortality from covid-19. all organizations in which physicians train and practice must redouble their efforts to recruit, train, and retain black physicians. if nothing else, the covid-19 pandemic must make academic health centers and health care systems recognize black physicians as the precious resource they are and protect and reward them accordingly. both the covid-19 pandemic and glaring police brutality have forced discussions of racial inequities in the united states, especially for blacks. from the public's now inescapable awareness of racial gaps in access to quality health care and the disproportionate burden of chronic health conditions borne by black communities come calls to address and redress health disparities. increasing the number of black physicians in the united states has been recommended as one means of advancing health equity. 1 data support this recommendation. compared with other physician groups, black physicians exhibit the least implicit racial bias 2 and practice in communities with relatively more black patients. black patients cared for by black physicians experience higher-quality care, lower hospital mortality rates, better communication, and more active involvement in health care decision making. 3 however, the u.s. physician workforce has relatively few black physicians. blacks comprise approximately 13% of the u.s. population but only 5% of practicing physicians. 4, 5 despite the association of american medical colleges' commitment to training a physician workforce that reflects u.s. demographics, blacks comprise only 7% of medical students. 4, 6 in this invited commentary, we caution that the covid-19 pandemic, as a further assault on the health of blacks in this country, may erode the meager progress that has been made in increasing the number of black physicians. this loss of black physicians may happen because blacks are overrepresented among cases of covid-19, black physicians care for relatively more black patients often in settings with less access to sars-cov-2 testing and personal protective equipment (ppe), and black physicians have more comorbid chronic conditions that increase their own susceptibility to mortality from covid-19. blacks make up 18% of the centers for disease control and prevention (cdc) covid-19-associated hospitalization surveillance network (covid-net) catchment area but have accounted for 33% of coronavirus-confirmed hospitalizations. 7 in milwaukee, wisconsin, 26% of the population is black, but approximately half of the covid-19 cases and 81% of related deaths have been among black patients, with similar trends reported in michigan, illinois, and north carolina. 8 multiple factors contribute to these disparities. compared with whites, blacks are more likely to engage in work that does not allow for social distancing (e.g., the service industry), live in housing that facilitates virus transmission, and have a greater prevalence of chronic conditions that predispose them to adverse outcomes once infected with sars-cov-2. a review of recent billing information by rubix life sciences found that, in spite of being at a considerably higher risk of exposure, blacks with covid-19 symptoms such as cough and fever were less likely than others to be tested for sars-cov-2. 9 in some cities, testing sites that were located in neighborhoods with relatively large numbers of black residents were inactive for weeks due to insufficient testing supplies. 9 like other health care workers, physicians are at risk of contracting covid-19 through exposure to the virus while providing care to infected patients or interacting with potentially contagious colleagues. black physicians' exposure to sars-cov-2 and risk of contracting covid-19 are proportionately greater abstract a compelling case exists that increasing the number of black physicians trained and practicing in the united states is one effective intervention to promote health equity and reduce the persistent health disparities that have become glaringly evident during the covid-19 pandemic. however, the u.s. physician workforce has relatively few black physicians. blacks comprise approximately 13% of the u.s. population but only 5% of practicing physicians. in this invited commentary, the authors caution that the covid-19 pandemic may erode the meager progress that has been made in increasing the number of black physicians. this loss of black physicians may happen because black patients are overrepresented among cases of covid-19, black physicians care for relatively more black patients often in settings with less access to sars-cov-2 testing and personal protective equipment, and black physicians have more comorbid chronic conditions that increase their own susceptibility to mortality from covid-19. all organizations in which physicians train and practice must redouble their efforts to recruit, train, and retain black physicians. if nothing else, the covid-19 pandemic must make academic health centers and health care systems recognize black physicians as the precious resource they are and protect and reward them accordingly. will losing black physicians be a consequence of the covid-19 pandemic? than other physicians because they are more likely to practice in areas with a higher population of black patients and in smaller institutions and community outpatient clinics that have been particularly under-resourced with ppe. this greater risk is borne out by data from the cdc, which found that blacks accounted for 21% of the 9,282 health care workers who have contracted covid-19 (including 184 intensive care unit admissions and 27 deaths), whereas blacks account for only 12% of all health care workers in the united states. 10 being responsible for providing care to a disproportionate number of patients with covid-19-especially at sites with inadequate resources-also places black physicians at greater risk for developing the mental health issues seen in health care workers dealing with the pandemic, including anxiety, depression, and posttraumatic stress disorder as well as imposter syndrome, loneliness, and survivor guilt. 11, 12 black physicians are more likely to have chronic health conditions that predispose them to mortality from covid-19 although physicians overall are healthier than the general population, health disparities manifest even between white and black physicians. 13 according to the cdc's national occupational mortality surveillance program, black physicians are far more likely than white physicians to have chronic health conditions such as hypertension, diabetes, chronic lung disease, and heart disease, which increase the mortality risk from covid-19. 7, 14 many factors may contribute to this difference, but black physicians also face systemic racism. 15 chronic exposure to the daily stressors of being black in the united states undoubtedly contributes to the greater burden of chronic health conditions and shorter life expectancy for black physicians compared with their white counterparts. 16 further, when black physicians enter the health care system as patients, they are at greater risk than their white colleagues of receiving lower-quality care at every level of disease severity and every stage of diagnosis and treatment for diseases affecting every organ system. 17 in addition to the influence of racial stereotypes on clinical decision making, 2 racial bias is built into many diagnostic criteria and clinical algorithms in ways that disadvantage black patients. 18 most of the race-based prejudice targeted at black physicians does not resemble the cruel acts of violence inflicted on george floyd, ahmaud arbery, or breonna taylor. however, the explicit and implicit acts of stereotype-based bias targeted at black physicians are acts of violence. academic medical centers and health care systems must no longer ignore the daily indignities black physicians suffer because of the color of their skin. 15 these institutions must implement policies to protect their black physicians from racist patients and from discriminatory evaluative practices. individuals within these institutions must educate themselves about how the mere existence of cultural stereotypes perpetuates inequities. all individuals must accept that exposure over time to the prevailing negative stereotypes about blacks can cause them to be unwittingly complicit in discrimination against all blacks, including black physicians. individuals must humbly accept that this discrimination will happen no matter how much they aspire to be fair and no matter how strongly they view themselves as egalitarian. this awareness must be accompanied by the willingness to engage in the hard work it takes to break these bias habits. 19 all organizations in which physicians train and practice must redouble their efforts to recruit, train, and retain black physicians. if nothing else, the covid-19 pandemic must make academic health centers and health care systems recognize black physicians as the precious resource they are and protect and reward them accordingly. funding/support: molly carnes receives funding from the national institutes of health (r35gm122557). the right thing to do, the smart thing to do: enhancing diversity and health professions physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities physician workforce disparities and patient care: a narrative review association of american medical colleges diversity in medicine: facts and figures 2019. figure 18. percentage of all active physicians by race/ethnicity diversity in medicine: facts and figures 2019. figure 8. percentage of matriculants to u.s. medical schools by race/ethnicity (alone), academic year hospitalization rates and characteristics of patients hospitalized with laboratoryconfirmed coronavirus disease 2019-covid-net, 14 states early data shows african americans have contracted and died of coronavirus at an alarming rate the coronavirus doesn't discriminate, but u.s. health care showing familiar biases. shots health news from npr bureau of health workforce, national center for health workforce analysis. sex, race, and ethnic diversity of national center for health workforce analysis the impact of the covid-19 pandemic on physician mental health. practice update factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019 mortality rates and causes among u.s. physicians discrimination toward physicians of color: a systematic review racism and health: evidence and needed research unequal treatment: confronting racial and ethnic disparities in health care other disclosures: none reported. key: cord-346487-f16uwuzv authors: landis, wayne g title: per‐ and polyfluoroalkyl substances, microplastics, and covid‐19: will we ever learn? date: 2020-06-15 journal: integr environ assess manag doi: 10.1002/ieam.4279 sha: doc_id: 346487 cord_uid: f16uwuzv nan at the time of this writing, the coronavirus pandemic has the attention of the entire world. it has been aptly referred by many scientists as the ultimate black swan event; that is to say, an extremely surprising random occurrence that is having a huge impact on the world economy and that experts try to explain away as something that was predictable, if only we had had the imagination to foresee it. the rapid spread of the virus to all corners of the globe, the number of infections, and the death toll are beyond belief in a world that unwittingly celebrated the beginning of a new decade just a few months ago. this global health emergency reminds us that we live in a deeply interconnected world. it focuses our attention on the most vulnerable in society, on the need for global cooperation, and on the importance of professional leadership and expertise. sound familiar? coronavirus disease 2019 (covid-19) is preceded by several environment and health emergencies that we felt, at that time, would also remind us of a shared humanity, our inseparable connection to the environment, and the need for unity. perhaps most prominent prior to the emergence of the coronavirus were the alarms sounding about the pervasive presence of plastic debris in our oceans, microplastics in the food chain and consumed by people, and the widespread use of the newly designated class of forever chemicals called per-and polyfluoroalkyl substances (pfas). in fact, these are the latest in a long list of emergencies and calls for action dating back to recognition in the 1960s of the dangers posed by ddt and pesticides and, thereafter, by hg, pcbs, dioxins, and flame retardant substances. in hindsight, each time our response has been predictable. shock and horror are soon replaced by laying blame and finger pointing, filing lawsuits (certainly true in the united states), and regulatory bans. with respect to chemical hazards, early reactions reflect our concerns for public health and as time passes migrate to the possible consequences for the environment and for wildlife. scientific studies are commissioned, investigation methods are devised, and work is conducted around the world. the results arrive, and scientific and legal arguments ensue, claiming bias in the study methods, analysis, and interpretation of the data used to support certain points of view. meanwhile, the onslaught of laboratory experiments and environmental monitoring continues, taking full advantage of the sudden availability of financial resources and opportunities to claim leadership and capture the public's worried attention. concurrent with this sequence of events is the deluge of papers submitted to scientific review panels and technical journals for peer review where the information is debated and more often than not found to be incomplete and requiring further investigation. the cause of the crisis is rarely understood. the scientific process takes years to clarify and at a snail's pace; all the while politicians formulate regulatory policy and move forward to appease a panicked public. and, so it goes…until the next black swan event. society should be increasingly immune to surprise by black swans. the ability to predict the consequences of human activities and technological inventions-both chemical and mechanical-have improved immensely during our professional lives. scientists understand well the consequences of human intervention in nature and subsequent cause-and-effect relationships. this has been our life's work. should we have been surprised that halogens bound to aromatic rings are persistent and resistant to degradation? that materials with high logp values bioaccumulate or biomagnify? should we have been caught unawares that volatile materials are transported by the atmosphere for long distances? if materials are made resistant to chemical, temperature, or biological degradation, then should we be surprised to find those same materials in our drinking water, soil, sediment, or biota? chemical structures and structureactivity relationships are well understood; so should we not be surprised, for example, when certain substances behave as predicted and affect metabolic pathways or disrupt endocrine functions? the fundamental question society faces today, and most certainly the scientific community, as a consequence of the ongoing coronavirus pandemic, is not whether we have sufficient knowledge of the fate and effects of chemicals or plastics or even viruses on the environment and human health; it is whether we are able to connect scientific observation and theoretical study to real-life consequences. we appear to suffer from a grand "not-in-my-backyard" attitude, wherein we have a void in our imaginations and ingenuity that inhibits our ability to translate science safely to the function and enjoyment of our daily lives. we simply do not have sufficient knowledge of our place in nature or control of our imaginations to foresee consequences, ask key questions, and to put a process in place. can it be that we fundamentally misunderstand cause and effect? pearl and mackenzie (2018) describes 3 levels on the ladder of causation. the ladder is a metaphor for understanding potential realities. the lowest step of the ladder is what he calls "seeing," that is, observing how variables may be associated. in statistics this level corresponds to observing associations. and although the late peter chapman would gladly remind us all that "association is not causation," associations can suggest places to investigate. the second step of the ladder is "intervention." experiments are interventions; the classic before-and-after control field design is another excellent case. however, experiments may lead to an understanding that after x, then y occurs, but not lead to the understanding of the mechanism. it is not the why or how question that is key to predicting a previously unrecognized or unobserved event. the third step of pearl's causation ladder is perhaps the rung scientists rarely step upon. it is labeled "counterfactual." here we must ask "what if" and "so what" questions. we must imagine new situations and retrospectively examine prior experiments and experiences to gain insight into causal mechanisms. an understanding of mechanisms helps us to explore more critical questions. for example, when hooper et al. (2013) ask how climate change affects biochemical pathways that regulate toxicity, carriger and barron (2011) imagine a variety of scenarios and the effects of different management options to mitigate the possibility for enhancing toxicity. graham et al. (2019) imagine even larger scale consequences for an entire region of the continent of australia. and by so imagining, we collectively avoid black swans. are we enlightened by the current events of covid-19 and are we likely to witness another global pandemic of biological or chemical origin in the future? most certainly, on both accounts. scientists need to be better at imagining new conditions, unexpected observations, assimilating experimental and field research into a series of mechanistic questions. scientists need to have an investigatory and management plan for plausible black swans. then when such an event occurs, it may have already been imagined and we have a process to understand the observation. for now, current events are an opportunity for discovery and to devise a strategic viewpoint, a careful process, and clear reporting. wayne g landis setac deputy editor, integrated environmental assessment and management minimizing risks from spilled oil to ecosystem services using influence diagrams: the deepwater horizon spill response using bayesian networks to predict risk to estuary water quality and patterns of benthic environmental dna in queensland interactions between chemical stressors: a role for mechanistic toxicology in assessment climate change risks the book of why: the new science of cause and effect key: cord-035226-z25efnjh authors: kumar, sumit; sherman, lawrence w.; strang, heather title: racial disparities in homicide victimisation rates: how to improve transparency by the office of national statistics in england and wales date: 2020-11-10 journal: camb j evid based polic doi: 10.1007/s41887-020-00055-y sha: doc_id: 35226 cord_uid: z25efnjh research question: how much racial disparity in trends of homicide victimisation rates in england and wales is obscured by the failure of official statistics to report rates of death per 100,000 people at risk? data: we collected two decades of homicide victimisation counts in england and wales, as broken out for each racial group identified by the office of national statistics. we also collected the estimated population size of those groups from the 2001 and 2011 census. methods: we divided the number of homicides in each racial category by the estimated population size of that category, by year, for 20 years, and plotted their relationships. findings: while white homicide victimisation rates remained low and stable from 2000 through 2019, black homicide victimisation ranged from 200 to 800% higher than that for the white population during that time period, at an average of 5.6 times higher for blacks. while black victimisation dropped by 69% from 2001 to 2012, it almost doubled (79% increase) from 2013 to 2019, rising seven times faster than the white victimisation rate. asian rates remained stable at about twice as high as white rates. for persons aged 16 to 24, the most recent homicide rate was 24 times higher for blacks than for whites. conclusion: none of these rates per 100,000 or ratios has been reported by the office of national statistics. if future ons reporting of homicide rates would include relevant denominators with raw numerators, public understanding of racial disparities in “over-policing” could be informed by potential “under-policing” relative to racial inequalities in homicide risk. the issue of systemic racism in policing is most often framed as one of greater intrusions by police upon minorities than upon whites, under similar circumstances. far more damaging in terms of the life expectancy of racial minorities, however, is the widespread systemic racial difference in homicide victimisation rates. when members of one group are far more likely to be murdered than members of other groups, it should be of equal concern as other disparities in mortality, such as from covid-19, for which official statistics in england and wales report death rates per 100,000 for whites vs ethnic minorities (white & nafilyan 2020) . that concern cannot be identified for homicide, however, if the rates themselves are not calculated and reported as a routine part of official statistics. official reporting of racially disaggregated homicide victimisation rates has long been a standard practice in the usa (reiss & roth 1993) , australia (strang, 1991) , and other economically advanced nations. yet as far as we can tell, homicide victimisation rates have never been reported by race in england and wales in the twenty-first century, either by the office of national statistics or by the home office before the ons took over the duty of reporting crime statistics. it is only the lack of adequate governmental transparency on risks of murder victimisation by race that makes it necessary to publish this research note. to be precise, what the crime statistics for england and wales fail to report by race is the simple division of the number of homicides in each racial group by the estimated number of people of that group residing in england and wales. this paper takes that simple step, in order to show important facts that have heretofore been largely invisible. it is an elementary principle of statistics that comparisons of raw numbers of rare events across groups of different sizes cannot be interpreted meaningfully. it is only by applying the basic idea of fractions that such comparisons can be interpreted. whatever the numerator may be, it takes a denominator to make it useful in comparing two groups. that is why, homicide comparisons across nations are expressed in rates of homicide per 100,000 people, rather than counts of people killed in nations of vastly different population sizes. while the 2020 office of national statistics (2020) annual report on homicide in england and wales reports the counts of homicide victims by ethnic classification, it does so without computing race-specific rates per 100,000. the report even offers, but does not deliver, these comparisons in section on "which groups of people were most likely to be victims of homicide?" yet the question is largely unanswered, limiting computation of homicides per 100,000s to differences across age groups, aggregated across all races. it does not give the reader any assistance in analysing the relative differences in rates of murder across different kinds of people or even different kinds of differences. sadly, the lack of comparable rates is a common problem in reporting important numbers. for well over 6 months of the covid-19 pandemic, bbc news reported daily infection counts of the number of infections detected in different locations, rather than a standardised rate per 100,000 people at risk of infection. the fact that the problem has now been corrected for covid-19 offers a precedent for ons to offer more differentiation in homicides per 100,000 across ethnicity, age, areas of the country, and combinations of this dimensions. this article illustrates what can be done by simple arithmetic with the published data from the last two decades. other important questions, such as the years of potential life lost (ypll), could also be considered for racial disparity, as well as disparities over time and across communities (see reiss and roth, eds. 1993) . such analyses can acquire greater investment if they can build on the foundation of racial disaggregation of homicide rates per 100,000 people. our research question is how much racial disparity in trends of homicide victimisation rates in england and wales is obscured by the failure of official statistics to report rates of death per 100,000 people at risk? we focus this question at the national level, but it could be equally applied to every one of the 43 territorial police forces in england and wales. we collected two decades of homicide victimisation counts in england and wales, as broken out by either the home office or the office of national statistics, for each racial group identified in the decennial census reports by the office of national statistics. we also collected the estimated population size of those groups from the 2001 and 2011 census. to the extent possible, we tried to match the definitions of ethnic groups between the census categories and the homicide categories. our challenge was that the classification of asian ethnicity in the census, and ons data of homicide victims was different. in the ons homicide victimisation data, asian included only victims from the indian subcontinent. in the census data, asian included people from all of the continent of asia. our least-worst solution to this challenge was to match the definition across the two datasets by using the following classification: white (white british, white irish, and white gypsy and white other); black (black african, black caribbean, and black other); asian, indian subcontinent (pakistan, india, bangladesh, sri lankan); and other (arabs; chinese; asian [other]; mixed; any other). using these definitions appears to offer the most precise common boundaries possible around numerators and denominators. we divided the number of homicides in each racial category by the estimated population size of that category, by year, for 20 years, and plotted their relationships. we did not estimate changing sizes of the population of each ethnic group considered. we applied the 2001 denominator up through 2010-2011 and then applied the 2011 denominator for all years thereafter. for one analysis only, we computed the rates of homicide for persons age 16-24 based solely on the 2011 census count of persons of that age in each ethnic group (actually using the population data for person age 15-24, which were readily available by ethnicity from the census). we were able to get the data by combination of age and ethnicity only from 2008 to 2018, with the 2011 census data falling near the middle of that time-span. thus, the statistics for calculating the rate for black and white victims per 100,000 people in this age group are based on just the 2011 census. we find racial differences in homicide victimisation rates between blacks and whites to be both substantial and dynamic. death rates are consistently higher for blacks than for whites and asians; asian death rates are about twice as high as for whites. the greatest difference visible from reported ons data is among persons aged 16-24, where the most recent statistics show black death rates to be 24 times higher per 100,000 than for whites. table 1 shows the raw data from homicide counts by ethnic group on which we base the analysis. it demonstrates the important point that by far, the largest number of homicide victims in each year is white. this means that white deaths can always dominate the news and that by raw numbers alone may obscure the vast differences in underlying risk by race. table 1 also shows that 2.5% had no record of victim ethnicity. that statistic, while small, is a finding that reflects violations of crime reporting requirements by police or others generating the initial crime report. table 2 reports the denominators and definitions we use for the ethnic classifications with which we calculate the death rates per 100,000 for each group. table 3 shows the annual homicide victimisation rates per 100,000 persons at risk in each ethnic classification for the first 19 years of the twenty-first century. these statistics are the underlying data for the comparison of trends in fig. 1 . figure 1 displays three trend lines across the first 19 years of the twenty-first century, one for each specific ethnic group. it shows that the black victimisation rate has been consistently the highest throughout this century and by a substantial margin. the mean rate for blacks is 5.6 times higher than for whites, while the most recent rate is 5.2. perhaps the most important pattern in fig. 1 is the massive drop in the black homicide victimisation rate from 8.1 in 2006-2007 to 2.9 in 2012-2013. despite that 64% decline in the black death rate, it was soon followed by an increase from 2015/ 2016 to 5.2 per 100,000 in 2018/2019-an increase of 79%. at the same time, the white death rate increased by only 11%, from 0.9 to 1.0 per 100,000. the black homicide victimisation rate therefore rose seven times faster than the white homicide death rate. figure 1 also shows how asian rates remained higher than the white rates but were far more stable than the black homicide victimisation rates. at no time were they as much higher than the white rates as the black rates were. table 4 displays the death rates per 100,000 by race and year for blacks and whites age 16-24, which is a point in the life span when homicide risk is often the highest (reiss and roth 1993; strang 1991) . the concentration of risk in those years, by definition, produces far higher rates of victimisation per 100,000. table 4 shows far greater racial disparity between blacks and whites in this age group than in the entire population. that difference does not occur by definition but by substantive differences in risks. while overall white rates may be reduced by a larger proportion of whites than of blacks in older age groups with lower homicide rates, that complexity is absent from table 4 . what that table displays is a more closely matched like-for-like comparison: given people in the same age group in england and wales, as between whites and blacks, who is more likely to be murdered? the answer is that blacks are almost 11 (10.6) times more likely to be murdered than whites. these differences do not control for sex. ons data do not include even raw numbers of homicide deaths by sex, age, and race combined. if they did, the concentration of murder victimisation among males would likely make these differences even more pronounced, as they are in the usa (reiss & roth 1993: 64) . figure 2 shows very little correlation between the death rate trends of young whites and young blacks. this is especially noticeable in the last 3 years of the time series, when the white homicide rate 16-24 dropped by 57%, while the black homicide victimisations per 100,000 age 16-24 increased by 31%. whatever the causes of the changes in each group, they appear to be largely independent of each other. these findings demonstrate the importance of making fair comparisons of risks based on fully calculated rates. while the principle is widely accepted, it is widely violated in practice. evidence-based policing requires reliable evidence, including rates of risk calculated in the same manner for all racial groups. only rates per 100,000 for any relevant numerator provide that kind of fair comparison. what these rates show in substantive terms is a substantial racial inequality in risks of being murdered in england and wales. while this article demonstrates inequality at a national level, it may be far greater-or even lower-in local areas, including police forces and their basic command units. while the ons is not funded to do such calculations, it is arguably essential that territorial police forces do so themselves. what the ons is funded to do is to publish meaningful statistics. the article shows how vast the racial differences are in england and wales in homicide victimisation rates per 100,000. these findings should provide all the evidence needed to expand annual (and retrospective) reporting of homicides to calculate race-specific and raceage-sex-specific rates of homicide victimisation per 100,000. these calculations do not require an increase in anyone's budget. they may, however, empower police to target racial disparities in a more precise way and to promote a more fact-informed dialogue with their many publics (bottoms and tankebe 2012) . these facts may even help to save lives. open access this article is licensed under a creative commons attribution 4.0 international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. beyond procedural justice: a dialogic approach to legitimacy in criminal justice understanding and preventing violence homicides in australia 1990-91. canberra: australian institute of criminology coronavirus (covid-19) related deaths by ethnic group publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations sumit kumar is a phd candidate at the jerry lee centre for experimental criminology, institute of criminology, university of cambridge, and a tutor at the cambridge centre for evidence-based policing ltd phd yale) is the director of the police executive programme and director of research at the jerry lee centre for experimental criminology key: cord-329310-8viyz7me authors: schwartz, stephan a. title: police brutality and racism in america date: 2020-07-02 journal: explore (ny) doi: 10.1016/j.explore.2020.06.010 sha: doc_id: 329310 cord_uid: 8viyz7me nan the schwartzreport tracks emerging trends that will affect the world, particularly the united states. for explore it focuses on matters of health in the broadest sense of that term, including medical issues, changes in the biosphere, technology, and policy considerations, all of which will shape our culture and our lives. after getting arrested several times for participating in civil rights demonstrations as i walked down constitution avenue, past what were then known as the old navy buildings, now long gone, on that warm wednesday afternoon on the 28 th of august 1963, i thought we had reached the turning point. i and thousands of others were moving quietly and peacefully towards the lincoln memorial where we were going to hear the reverend martin luther king give what history now knows as the "i have a dream speech." i was walking with a black friend, a reporter for the washington star, an historic paper now long gone. i looked over richard's shoulder and saw walking next to us two young partners of the then conservative republican law firm, covington & burling. richard saw where i was looking and turned to watch them as well. to him they were just two more white men; a large proportion of the crowd were white, and men. when i explained who they were he smiled, and i said, "i think we've won." it was such a happy day; i remember it still. and a little less than a year later, on 2 july 1964, almost unthinkably, a southern politician, president lyndon johnson, signed into law the bipartisan civil rights act of 1964, which prohibited discrimination in public places, provided for the integration of public schools, and facilities, and made employment discrimination based on race illegal. it seemed dr. king's dream was coming true. police brutality and racism in america ❖. stephan. a. schwartz page 2 then a year after that when johnson signed the voting rights act of 1965, which outlawed discriminatory voting practices, such as literacy tests and poll taxes, i thought all was now well. it had taken almost a hundred years, but we were finally throttling the monster of racism. and yet here i sit, looking day after day at the searing television images of the new civil rights demonstrations, watching videos of white policemen murdering black men for no reason except they could, thinking they would get away with it, as they had so often in the past. the mass demonstrations with their clouds of tear gas and rubber bullets. the gross misuse of the american military against american citizens. the eight minutes and 46 seconds of video showing four policemen in minneapolis murdering an unarmed handcuffed black man, george floyd, as he lay in the street handcuffed, that has caused, as i write this, 19 days of civil rights demonstrations involving millions all over the world. it is important to remember also, i think, that this historic event, the murder and everything that has followed from that death is known to us only because of the bravery of one 17-year old girl, darnell frazier, who would not be intimidated and kept phone camera on. as her hometown paper, the star tribune reported, frazier wasn't looking to be a hero. she was "just a 17-year-old high school student, with a boyfriend and a job at the mall, who did the right thing. she's the rosa parks of her generation." 1 i completely agree. i have written often about the power of a single individual at the right moment. 2 could there be a clearer example? what made this event historic, so catalyzing, so emotionally powerful that people all over the world in their millions took to the streets, even though it could mean their life because the covid-19 pandemic which, in the u.s. alone, had infected over two million people and was still killing a thousand people a day? i think it was because it illustrated the conjunction of two major trends in america: the blatant racism that still infects the country, and the racially biased police brutality which has become outrageous. george floyd is one of a thousand police killings that will probably happen in 2020. there were that many last year. the statistics about american law enforcement are astounding when compared to those of other developed nations, like those that make up the organisation for economic cooperation and development (oecd). according to statistia, "with a total 429 civilians having been shot, 88 of whom were black, as of june 4, 2020. in 2018, there were 996 fatal police shootings, and in 2019 this figure increased to 1,004. additionally, the rate of fatal police shootings among black americans was much higher than that for any other ethnicity, standing at 30 fatal shootings per million of the population as of june 2020." 3 by way of contrast, in norway, which i pick because it is a nation with very high gun ownership, the police in 2019 armed themselves and displayed weapons 42 times, and fired two guns once each. few americans even realize that "a police officer does not have to shoot to kill and, in several countries, a police officer does not even have to carry a gun. in norway, iceland, new zealand, britain, and ireland, police officers generally do not carry firearms." 4 intermixed with racial brutality on the part of the law enforcement system in the u.s. is the gross misuse of the american military against the american people they are sworn to protect. and then there is the american gulag. it's prisons and jails dot our national landscape holding millions of incarcerated men and women a large majority of them black and brown. until this june i don't think most americans really understood how violent and racist policing in america has become. if you are white like me, professional and relatively affluent, you never have any interactions with the police. they don't come to your door, and should it happen that you are stopped for a traffic ticket you don't feel threatened; it is no more than an annoyance that is going to cost you a few dollars for the fine. and even then, how often does that happen? i haven't been stopped since 1973, when a taillight on my car had gone out without my noticing. you see the police, they are there. but it is not an issue. but if you are black or brown you live in another world. three weeks before george floyd was murdered during a traffic stop by four police officers, an exhaustive study carried out by a research team at stanford university led by emma "we assessed racial disparities in policing in the united states by compiling and analysing a dataset detailing nearly 100 million traffic stops conducted across the country. we found that black drivers were less likely to be stopped after sunset, when a 'veil of darkness' masks one's race, suggesting bias in stop decisions. furthermore, by examining the rate at which stopped drivers were searched and the likelihood that searches turned up contraband, we found evidence that the bar for searching black and hispanic drivers was lower than that for searching white drivers. finally, we found that legalization of recreational marijuana reduced the number of searches of white, black and hispanic drivers-but the bar for searching black and hispanic drivers was still lower than that for white drivers post-legalization. our results indicate that police stops and search decisions suffer from persistent racial bias and point to the value of policy interventions to mitigate these disparities." 5 some years ago i was on the board of a foundation to help children in medical distress. also on the board was the then deputy chief of police of the los angeles police department. we became friendly and one night went out to dinner together after a board meeting. this was not long after the 1992 riots that occurred when rodney king, a black man, was savagely beaten by police in a traffic stop. i asked the deputy chief, who had told me he had risen through the ranks and been a sworn officer for almost 30 years, how many police officers would participate in something like the king beating? i have never forgotten his answer. he said, "about 15% of police are heroes, the very best you could ever ask for. another 15% are thugs and bullies who become police because they think they can act out without fear of punishment. the remaining 70% go with the flow. if they are with heroes, they behave heroically; if they are assigned to work with thugs, well bad things happen." he explained that what he was trying to do was identify the thugs before they were hired. and to break through the "blue wall" if they are hired. he told me it was not easy, and one of the problems was the police union which protected its members at all cost. how bad is it? i mean real numbers, not just the conjecture and political commentary that fills the airwaves. it turns out that it is very hard to get this information. because of the power of the police unions and the racism of the u.s. congress under the last four presidents, both democrats and republicans -bill clinton, george w. bush, barrack obama, and donald trump -as police violence has grown worse each year, creating a real federal data base on police violence has proven almost impossible. in 1994 congress passed h.r. 3355 violent crime control and law enforcement act of 1994. 6 it provided funds for local and state law enforcement entities and the state attorney generals to "acquire data about the use of excessive force by law enforcement police brutality and racism in america ❖. stephan. a. schwartz page 5 officers" across the nation and to "publish an annual summary of the data acquired." it didn't go well. in 1996, the institute for law and justice and the national institute of justice on behalf of the doj, in a carefully worded report, described the failure to do what was mandated two years earlier. "systematically collecting information on use of force from the nation's more than 17,000 law enforcement agencies is difficult given the lack of standard definitions, the variety of incident recording practices, and the sensitivity of the issue." 7 so in 2020, do we know any more? we do, although still far from enough. in 2019, a research team led by frank edwards of the school of criminal justice at rutgers university, published a report, "risk of being killed by police use-of-foce in the u.s. by age, race/ethnicity, and sex." they reported: "we use novel data on police-involved deaths to estimate how the risk of being killed by police use-of-force in the united states varies across social groups. we estimate the lifetime and age-specific risks of being killed by police by race and sex. we also provide estimates of the proportion of all deaths accounted for by police use-of-force. we find that african american men and women, american indian / alaska native men and women, and latino men face higher lifetime risk of being killed by police than do their white peers. we find that latino women and asian / pacific islander men and women face lower risk of being killed by police than do their white peers. risk is highest for black men, who (at current levels of risk) face about a 1 in 1,000 chance of being killed by police over the life course. the average lifetime odds of being killed by police are about 1 in 2,000 for men and about 1 in 33,000 for women. risk peaks between the ages of 20 and 35 for all groups. for young men of color, police use-of-force is among the leading causes of death." 8 just to put that in a little finer focus, what they are saying is: "african american men were about 2 1 /2 times more likely than white men to be killed by police. men of color face a nontrivial lifetime risk of being killed by police" 9 the washington post looked into this issue and tuned the data even finer: "although half of the people shot and killed by police are white, black americans are shot at a disproportionate rate. they account for just 13 percent of the u.s. population, but more than a quarter of police shooting victims. the disparity is even more pronounced among unarmed victims, of whom more than a third are black." 10 police brutality and racism in america ❖. stephan. a. schwartz page 6 and if you are black or brown, while being murdered is the worst case scenario it is not the only misery that awaits any interaction with america's racist police. a study carried out by megan t. stevenson and sandra mayson that was published in 2018 in the boston university law review described the reality of being a black person on the streets of america. in doing their research stevenson and mayson discovered first that the hysteria about crime built up in america by conservative politicians and commentators, who are overwhelmingly white, is unfounded. "the number of misdemeanor arrests and cases filed have declined markedly in recent years. in fact, national arrest rates for almost every misdemeanor offense category have been declining for at least two decades, and the misdemeanor arrest rate was lower in 2014 than in 1995 in almost every state for which data is available." 11 but they also found, "there is profound racial disparity in the misdemeanor arrest rate for most-but not all-offense types. this is sobering if not surprising. more unexpectedly, perhaps, the variation in racial disparity across offense types has remained remarkably constant over the past thirty-seven years; the offenses marked by the greatest racial disparity in arrest rates in 1980 are more or less the same as those marked by greatest racial disparity today." 12 the truth that almost none of us who are white get is that 57 years after martin luther king's i have a dream speech, 56 years after the civil rights act of 1964, and 55 years after the voting rights act of 1965, if you are black or brown, and particularly if you are a young black man, for you america is like living in an occupied country, where any interaction with the police is to be avoided. it can send you to prison for a trivial offense at the least, and may, and often does, result in your murder at the hands of those whose supposed but not actual job is to "serve and protect." speaking as a white man, i am fed up with that, and i think that this november all of us who are white and who believe the function of the state should be to foster wellbeing at every level, for everyone, need to check off our ballots only for candidates who are willing to do that, and vote out of office all politicians not so committed. what do you think? scientist, futurist, and award-winning author and novelist stephan a. schwartz teen who recorded george floyd video wasn't looking to be a hero number of people shot to death by the police in the united states from how do police handle violence in countries where officers don't carry guns? quartz a large-scale analysis of racial disparities in police stops across the united states 3355 -violent crime control and law enforcement act of national data collection on police use of force. institute for law and justice, jointly published with the national institute of justice risk of being killed by police use-of-force in the u.s. by age, race/ethnicity, and sex what we've learned about police shootings 5 years after ferguson the scale of misdemeanor justice key: cord-332065-afq26621 authors: ghanchi, hammad; patchana, tye; wiginton, james; browne, jonathan d; ohno, ai; farahmandian, ronit; duong, jason; cortez, vladimir; miulli, dan e title: racial disparity amongst stroke patients during the coronavirus disease 2019 pandemic date: 2020-09-10 journal: cureus doi: 10.7759/cureus.10369 sha: doc_id: 332065 cord_uid: afq26621 introduction the global coronavirus disease 2019 (covid-19) pandemic has had deleterious effects on our healthcare system. lockdown measures have decreased the number of patients presenting to the hospital for non-respiratory illnesses, such as strokes. moreover, there appears to be a racial disparity among those afflicted with the virus. we sought to assess whether this disparity also existed for patients presenting with strokes. methods the get with the guidelines national stroke database was reviewed to assess patients presenting with a final diagnosis of ischemic stroke, transient ischemic attack (tia), subarachnoid hemorrhage (sah), or spontaneous/nontraumatic intraparenchymal hemorrhage (iph). the period of february may 2020 was chosen given the surge of patients affected with the virus and national shutdowns. data from this same time during 2019 was used as the control population. our hospital numbers and four additional regions were assessed (california hospitals, pacific state hospitals, western region hospitals, and all hospitals in the united states). patients were categorized by race (white, black/african american, asian, native american, hispanic) in each cohort. the primary endpoint of this study is to compare whether there was a significant difference in the proportion of patients in each reported racial category presenting with stroke during the covid-19 pandemic caused by severe acute respiratory syndrome coronavirus 2 (sars-cov-2). results a downward trend in total number of patients was noted in all five regional cohorts assessed. a statistically significant increase in the number of black and hispanic patients presenting with strokes was noted in california, pacific hospitals, western hospitals, and all hospitals in the united states during various months studied comparing 2020 to 2019. a statistically significant increase in the hispanic population was noted in february and march in all california hospitals (p=0.005 and 0.02, respectively) and pacific coast hospitals (p=0.005 and 0.039, respectively). the western region and all national hospitals noted a significant increase in strokes in the hispanic population in april (p=0.039 and 0.023, respectively). a statistically significant increase of strokes in the black population was noted in april in pacific hospitals, western region hospitals, and all national hospitals (p=0.039, 0.03, and 0.03, respectively). conclusion the covid-19 pandemic has adversely affected certain racial groups more than others. a similar increase is noted in patients presenting with strokes in these specific racial populations. moreover, lack of testing for the sars-cov-2 virus may be missing a possible link between racial disparity for patients infected with the virus and patients presenting with stroke. the authors advocate for widespread testing for all patients to further assess this correlation. the coronavirus disease 2019 pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (sars-cov-2), has affected many aspects of healthcare, including stroke care. significant racial disparities among populations affected by covid19 have recently made headlines. some sources have also cited sars-cov-2 as a possible cause of stroke [1] . nationally, hispanics and blacks are disproportionately represented among laboratory-confirmed covid-19 cases [2] . as of june 27, age-adjusted covid-19-associated hospitalization rates were highest among people who are non-hispanic american indian/alaska native, non-hispanic black, and hispanic/latino according to the covid-19-associated hospitalization surveillance network (covid-net) [3] . higher rates of covid-19 deaths were reported in counties with a high black population, especially in rural and small metro counties [4] . this is not the first time in history that racial disparity has existed in medicine; surgeries on black women without anesthesia by dr. sims [5] and the tuskegee syphilis study are two examples of racism and prejudice that have caused distrust towards the medical sciences among this population [6] . there are no known unethical practices during the recent pandemic, however, this lingering mistrust can lead to delayed presentation in the setting of stroke and render black patients to be ineligible for receiving intravenous tissue plasminogen activator (iv-tpa) treatment [7] . despite the national decline in the mortality rate from stroke, it remains the second leading cause of death in blacks [8] . moreover, black individuals have been shown to have a higher mortality rate [9] and a higher chance of experiencing disability [10] following a stroke compared to whites. furthermore, the american heart association (aha) stroke council scientific oversight committee has reported a history of racial discrepancies in stroke risk factors, incidence, prevalence, and symptom recognition [11] . given the recent pandemic and racial disparity among patients afflicted with sars-cov-2 and the possible link of this virus and cerebrovascular accidents (cva), we sought to analyze whether there was a disparity for stroke patients presenting to hospitals during this time using the get with the guidelines (gwtg) national stroke database. the primary endpoint of this study is to assess whether disparity exists at our own hospital. we also wanted to expand this scope to the regional and national levels to assess for any possible racial disparities. the gwtg stroke registry at our institution, a level 1 primary stroke center certified by the healthcare facilities accreditation program, was retrospectively reviewed to assess the impact of the sars-cov-2 outbreak on the number of patients presenting with stroke to our hospital. demographics with regards to patients' race were collected. data were stratified by date and comparison was made between the covid-19 period (february -may 2020) and similar timeframe pre-covid-19 (february -may 2019). the months preceding the covid-19 period (october 2019 -janurary 2020) were avoided as a control as it is hard to know whether sars-cov-2 was propagating in the population during this time. the gwtg database was used to review records at our hospital, all california hospitals, west and pacific regions, and all hospitals nationally. patients presenting to these hospitals with a final diagnosis of ischemic stroke, transient ischemic attack (tia), subarachnoid hemorrhage (sah), or spontaneous/nontraumatic intraparenchymal hemorrhage (iph) were reviewed. after data was extracted from the database, the cohorts were stratified into five groups: (a) our hospital, (b) all california hospitals, (c) all pacific coast hospitals (alaska, washington, oregon, california, and hawaii), (d) all western hospitals (pacific plus montana, idaho, wyoming, nevada, utah, colorado, arizona, and new mexico), and (e) all hospitals in the united states that submit data to the registry. among these groups, the number and relative proportion of each reported race (white, black/african american, asian, native american, or hispanic) were reviewed each month during covid-19 and a similar time frame pre-covid-19. proportions were chosen instead of volume of patients to limit any confounding decreases/changes in the number of patients in each time frame as recent data has suggested a decrease in total number of stroke patients presenting to the hospital during this time [12] . the primary endpoint of this study is to compare whether there was a significant difference in the proportion of patients in each reported racial category presenting to our institution with stroke during the covid-19 pandemic caused by sars-cov-2. the same analysis was conducted for the pacific hospitals, western hospitals, and all national hospitals. statistical analysis was performed using z-test to compare the proportions for all races for any significant difference month by month (i.e. february 2019 compared to february 2020, march 2019 compared to march 2020, etc.). there was an average of 51.75 patients per month in 2019 and 49 patients per month in 2020 during the time frame studied at our hospital. this downward trend in 2020 compared to 2019 in total patients per month was echoed in all the groups studied (california, pacific, western region, and national). the total number of patients in each subgroup can be viewed in the appendix. to remove the confounding effect of decreased patient numbers, as this decrease became more evident on the regional and national levels (i.e. mean of 57,864.5 patients nationally february through may 2019 versus 45,927.75 patients during the same months in 2020) during the covid-19 months, the percentage of each race presenting to each hospital category was calculated (see appendix). looking at our hospital's local population, a significant difference in native hawaiian/pacific islander population was noted in february 2020 compared to 2019 (p=0.01) but other racial cohorts remained similar ( table 1) . data for asian and american indian or american native populations were insufficiently powered to perform statistical analysis. expanding the scope to include all california hospitals, a significant difference was noted again in the native hawaiian/pacific islander population in february 2020 compared to the prior year (p<0.01). the hispanic population also showed a significant difference for the months of february and march (p=0.005 and p=0.02, respectively). the remainder of racial cohorts in california remained stable during the studied time studied. racial disparities are well documented in all aspects of stroke as it relates to differences in stroke risk factors, incidence, prevalence, and symptom recognition in comparison to the white population [11] . while disparity in stroke may partially be explained by geography [13] , neighborhood socioeconomic status [14] , or age [15] , there is substantial evidence emphasizing racial predisposition to stroke. the first-stroke risk at age 45 is 2.7 times higher in black individuals compared to white individuals, with black patients having higher rates of ischemic and hemorrhagic stroke [16] . in one cohort study, black patients also had a 60% greater risk of recurrent stroke within two years compared to white patients, as well as higher prevalence of key vascular risk factors, including hypertension, diabetes mellitus, smoking, and high bmi [17] . prevalence of underlying comorbidities and differences in leisure-time physical activity and diet may be contributing to the racial disparity among patients presenting with stroke prior to and during the covid-19 period. among patients hospitalized for covid-19 with data on underlying conditions, 89.3% had at least one underlying condition according to the u.s. centers for disease control and prevention [18] . these included preventable vascular risk factors related to poor diet and physical inactivity, such as hypertension, cardiovascular disease, obesity, and diabetes [19] . relative to non-hispanic whites, blacks have historically been found to be less physically active [20] and have poorer diets [21] . this trend is consistent with the disproportionate increase in blacks presenting with stroke on a national level in march 2020 from the prior year. in contrast, hispanics have been found to have healthier diets than whites [21] [22] [23] although poorer diets have been reported among those with high acculturation status [23] . this interaction between acculturation status and dietary behavior may be contributing to the difference in trend seen among hispanic patients presenting with stroke at a regional versus national level. as of late june 2020, age-adjusted covid-19-associated hospitalization rates were highest among people who are non-hispanic american indian/alaska native, non-hispanic black, and hispanic/latino according to the covid-19-associated hospitalization surveillance network (covid-net) [ it has previously been reported that covid-19 patients may present with ischemic stroke [24] . influenza-like illnesses have also been linked to stroke [25] . while yet to be proven, there are several proposals on how covid-19 may increase the risk of stroke. angiotensin converting enzyme (ace) ii receptor is a functional receptor and entry point for sars-cov and sars-cov-2. involved in cardiovascular homeostasis, the receptor is expressed on several vital tissues, including vascular endothelium, arterial smooth muscle, and the brain [26] . sars-cov infection appears to downregulate ace ii [27] , which may contribute to increased stroke risk. cardiac embolism from virus-related cardiac injury [28] , hypercoagulability exhibited by elevated d-dimer levels [29] , and inflammatory reactions due to cytokine storm [30] are other mechanisms in which covid-19 may lead to increased risk of stroke. stress from lockdowninduced isolation increases sympathetic release cytokines which affects the comorbidities of this end-organ disease. these factors amplify the effects of stroke in this population. furthermore, during the month of february 2020, the data demonstrate an increase in the total number of patients presenting with strokes in all subgroups (appendix table 2 ). given the possibility of sars-cov-2 causing vascular injury, this rise may be attributed to early stages of the covid-19 pandemic, i.e. sars-cov-2 was propagating in february in the united states possibly causing increase in stroke numbers. this rise in total numbers was then mitigated during the following months by the nationwide lockdowns and patient fears of contracting the infection. testing for sars-cov-2 was not being performed at this time, so this postulation is difficult to prove. moreover, given the possibility of carriers of this virus being asymptomatic from a respiratory standpoint, patients presenting with stroke may fall into this category. one major limitation of this study is the lack of widespread testing for sars-cov-2. the cause for the increase in the number of strokes in february 2020 before lockdown measures is uncertain but given the virus was circulating during this time along with the vascular injury it causes make it a possible suspect. moreover, lack of widespread testing the months following also limits our ability to assess whether the increase in certain races being more adversely affected from the virus and increase in the number of strokes in the same ethic groups is related. thus, we hope to advocate for universal testing for sars-cov-2 for all patients presenting to the hospital to further isolate possible carriers who are asymptomatic from a respiratory standpoint. moreover, given the retrospective nature of this study, we are unable to retroactively implement these goals. the global covid-19 pandemic has had many devastating effects on not only our economy and lifestyles, but also our healthcare system. certain races are being more adversely affected than others from this virus due to the effects on the human physiology and the ability of the virus amplify the negative health effects of the comorbid conditions of stroke. the potential for this virus to cause strokes may be causing our observed increase in minority cerebrovascular accidents. increase in stroke numbers prior to lockdowns may be related to early propagation of the virus. further work is needed to assess this relationship as well as more widespread testing for sars-cov-2 to determine the true pathophysiology of this illness. human subjects: consent was obtained by all participants in this study. animal subjects: all authors have confirmed that this study did not involve animal subjects or tissue. conflicts of interest: in compliance with the icmje uniform disclosure form, all authors declare the following: payment/services info: all authors have declared that no financial support was received from any organization for the submitted work. financial relationships: all authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. other relationships: all authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work. characteristics and outcomes of covid-19 patients in new york city's public hospital system coronavirus disease 2019 case surveillance -united states accessed assessing differential impacts of covid-19 on black communities the medical ethics of the "father of gynaecology disparities and distrust: the implications of psychological processes for understanding racial disparities in health and health care racial disparities in tissue plasminogen activator treatment rate for stroke: a population-based study stroke declines from third to fourth leading cause of death in the united states: historical perspective and challenges ahead reasons for geographic and racial differences in stroke (regards) investigators. ethnic disparities in stroke: the scope of the problem divergent poststroke outcomes for black patients: lower mortality, but greater disability racial-ethnic disparities in stroke care: the american experience: a statement for healthcare professionals from the american heart association/american stroke association effects of the covid-19 pandemic on stroke patients. cureus. 2020 racial disparities in stroke risk factors: the impact of socioeconomic status neighborhood socioeconomic index and stroke incidence in a national cohort of blacks and whites sex and race differences in the association of incident ischemic stroke with risk factors trends and racial differences in first hospitalization for stroke and 30-day mortality in the us medicare population from 1988 to 2013 association of black race with recurrent stroke risk hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed coronavirus disease 2019 nutrition and health are closely related -2015-2020 dietary guidelines racial/ethnic disparities in exercise and dietary behaviors of middleaged and older adults racial/ethnic disparities in dietary intake of u.s. children participating in wic racial/ethnic disparities in us adolescents' dietary quality and its modification by weight-related factors and physical activity higher fat intake and lower fruit and vegetables intakes are associated with greater acculturation among mexicans living in washington state covid-19 presenting as stroke influenza-like illness as a trigger for ischemic stroke severe acute respiratory syndrome coronavirus 2 infection and ischemic stroke sars-coronavirus modulation of myocardial ace2 expression and inflammation in patients with sars covid-19 and the heart neurologic manifestations of hospitalized patients with coronavirus disease 2019 in wuhan, china influence of covid-19 on cerebrovascular disease and its possible mechanism key: cord-266132-i57avso9 authors: kirksey, lee; tucker, dominique l.; taylor, eddie; white solaru, khendi t.; modlin, charles s. title: pandemic superimposed on epidemic: covid-19 disparities in black americans date: 2020-08-01 journal: j natl med assoc doi: 10.1016/j.jnma.2020.07.003 sha: doc_id: 266132 cord_uid: i57avso9 health and healthcare disparities are variances in the health of a population or the care rendered to a population. disparities result in a disproportionately higher prevalence of disease or lower standard of care provided to the index group. multiple theories exist regarding the genesis of this disturbing finding. the covid-19 pandemic has had the unfortunate effect of amplifying health inequity in vulnerable populations. african americans, who make up approximately 12% of the us population are reportedly being diagnosed with covid-19 and dying at disproportionately higher rates. viewed holistically, multiple factors are contributing to the perfect storm: 1) limited availability of public testing, 2) a dramatic increase in low wage worker unemployment/health insurance loss especially in the service sector of the economy, 3) high rates of preexisting chronic disease states/reduced access to early healthcare and 4) individual provider and structural healthcare system bias. indeed, covid-19 represents a pandemic superimposed on a historic epidemic of racial health inequity and healthcare disparities. therapeutic solutions are not expected in the near term. thus, identifying the genesis and magnitude of covid-19's impact on african american communities is the requisite first step toward crafting an immediate well designed response. the mid and long term approach should incorporate population health based tactics and strategies. h ealth and healthcare disparities are variances in the health of a population or the care rendered to a population. disparities result in a disproportionately higher prevalence of disease or a lower standard of care provided to the index group. multiple theories exist regarding the genesis of this disturbing finding. structural societal issues such as historical redlining policies affecting residential housing and neighborhood safety, public school quality, access to healthy foods and livable wage employment opportunities directly impact health from birth. the impact of these environmental challenges may dramatically influence an affected individual's health over the course of their life. 1 in metropolitan areas, the difference of several miles and a change of zip codes may be associated with an increase in the prevalence of chronic disease and consequent shortened lifespans amongst the residents of poorer communities. 2 in the best of times, chronic diseases such as diabetes, hypertension, coronary artery disease, kidney disease, cancer, stroke and other conditions occur with higher prevalence in blacks. 3 consequently, on either end of life, blacks experience both higher rates of infant mortality and shorter life expectancies relative to their white counterparts. 4 sars-cov-2 is responsible for covid-19, a contagious respiratory illness. the first reported case is believed to have originated in wuhan, china. the world health organization has designated the covid-19 pandemic a public health emergency of international concern. 5 two factors are associated with increased susceptibility to covid-19: advanced age and underlying chronic medical conditions. 6, 7 the covid-19 pandemic has had the unfortunate effect of amplifying health inequity in vulnerable populations. african americans, who make up approximately 12% of the us population are reportedly being diagnosed with covid-19 and dying at disproportionately higher rates. the early data reveals this alarming trend to be occurring in various parts of the country ( table 1) . 8e11 the lack of definitive data on testing rates, confirmed cases and mortality highlight issues around covid-19 race/ethnic data collection and reporting process at the local, state and federal level through the cdc. 12,13 indeed, the cdc's data collection form for patients under investigation and confirmed case reports requests ethnic demographics. 14 however, in some states, racial and ethnic data has been reported to be unavailable in up to 40% of confirmed cases. 14 unfortunately, the fact that not all local, state and federal public health agencies are collecting race and ethnic data points will contribute to delays in reaching a complete understanding of the magnitude of this pandemic's impact on black communities ( figure 1 ). however, it is clear that the finding that covid-19 is disproportionately afflicting and killing more african americans is more than a statistical aberrancy. accurate public reporting of tests administered, confirmed positive results and patient outcomes for blacks will allow strategic planning and public health efforts to be effectively and equitably deployed and implemented. the finding of disparate health outcomes in african americans is not a novel concept. for years it has been scientifically validated and accepted that where we live, where we learn, work and play all fundamentally affect our personal health including the prevalence of chronic health conditions ( figure 2 ). 15 of all measures of socioeconomic status (ses), educational attainment is perhaps the single best indicator that has the most consistent association with metrics of health including all cause and cause specific mortality. 16 low ses is associated with the earlier onset of chronic medical conditions, on average 10e15 years sooner than high ses communities. 17 minorities including african americans disproportionately represent service industry workers including early care and education, restaurant workers, food processors. these individuals experience disproportionately higher levels of covid-19 exposure as a result of high rates of public interaction. defying public health recommendations during the covid-19 pandemic, where "physical distancing" has been mandated legislatively is not an option for these "essential worker" groups. stratifying across economic levels, 93% of highest wage earners (top 10%) were able to earn paid sick days whereas only 30% of lowest earners (bottom 10%) were able to earn sick days. 18, 19 this fundamental shortcoming in worker benefits denies minorities, including blacks, the privilege of sheltering in place and working from home. additionally, in metropolitan areas like chicago, detroit and new orleans, lower income workers disproportionally rely upon mass public transportation at a greater rate. currently up to 27 million americans are uninsured. 20 however, health insurance coverage is not the sole determinant of healthcare outcomes. 21 insurance status notwithstanding, african americans are more likely to have a medicaid health insurance product which may provide them with limited access to primary care physicians and no broad-based healthcare benefits portfolio. moreover, low wage service workers are less likely to have uninterrupted healthcare insurance due to job transitions rendering them "underinsured". 21 viewed holistically multiple factors are contributing to the perfect storm: 1) limited availability of public testing, 2) a dramatic increase in low wage worker unemployment/health insurance loss especially in the service sector of the economy, 3) high rates of pre-existing chronic disease states/reduced access to early healthcare and 4) individual and structural healthcare system bias. once hospitalized, black patients are vulnerable to the impact of implicit and explicit healthcare provider bias. stereotypes and biases are more likely to affect decision making in times of emotional stress and anxiety-both of which are more likely in the covid-19 surge and peak phase when providers and the healthcare system are stretched to capacity. all human beings harbor bias of some sort and it is only with the acknowledgment of this fact that we can effectively manage ourselves. 22 bias may occur from the time when decisions regarding the "selective" offering of covid-19 testing to individuals are made all the way across the care spectrum to the point of deciding who will be intubated and in whom care is going to be withdrawn because of perceived "futility of further care". bias can be mitigated by the application of evidence based protocols that provide guidance with enough leeway for judicious application of prudent physician clinical judgment. triage teams which employ a team of clinicians including a bio-ethicist may be helpful to mitigate the 'moral burden' of a single physician making critical decisions on their own. accurate and timely documentation of the exact number of tests performed, confirmed covid-19 cases and fatalities within the black population is the essential first step. this must occur at the municipal, state and federal level and mandates should be issued to private testing laboratories as more testing is relegated to private entities. this should be extended to new testing methods, like plasma antibody serology testing, as they come online. in the interest of transparency, these data should be reported to the public at all levels including by the cdc. with the detrimental impact of social determinants of health in mind, testing that is available to the public, but not accessible to some communities is ineffective for identifying problematic areas and performing contact tracing and other public health initiatives to mitigate the spread of covid-19 infection. until therapeutics are available in the form of vaccinations, a strategic and broadbased public health approach will continue to be the centerpiece approach to covid-19. to overcome limiting geographic factors such as a dependence on public transportation, as public testing is accelerated, efforts should be focused on locating the testing centers within underserved neighborhoods. effective advertising campaigns will be needed to overcome the historic distrust associated with population testing and perceived stigma of positive test results. media reports have documented the circulation of "urban myths" that young blacks are not susceptible to covid-19 and that only the elderly are effected. instead, in a population where a disproportionate number of individuals suffer from diabetes, hypertension and other chronic conditions earlier in life; campaigns should focus on dispelling such myths. faith based organizations should play a role in disseminating this information. visible community leaders should be called upon. african american health providers who are known to the community and have established trusting relationships should be active in disseminating important, timely and accurate healthcare messaging. the understanding of clinical immunity following covid-19 infection and the role, if any, that accurate serum plasma testing plays will be a critical step. communicating that those who have suffered and resolved the disease, sometimes with mild or no symptoms, will have the ability to return to work more easily and to resume daily life is crucial to family economic viability and stimulating the local economic community. wide scale covid-19 testing, contact tracing of those found positive for infection and timely quarantining of contacts will require equitable distribution of federal funding to build out a robust public health tracing program. on the behalf of healthcare institutions servicing disproportionately impacted black communities, motivation exists beyond the fact that there is a "moral imperative" to treat all populations with equal care. a profound business case can be made that improving care within underserved groups will reduce emergency department visits, hospitalizations for costly advanced stage covid-19 presentations and allow healthcare facilities to emerge from the covid-19 fog and resume a more normal business pattern. indeed, covid-19 represents a pandemic superimposed on a historic epidemic of health and healthcare disparities. given the fact that therapeutics solutions are not expected in the near term-identifying the genesis and magnitude of covid-19's impact on african american communities is the requisite first step toward crafting and immediate response. the mid and long term approach should incorporate population health based tactics and strategies. this study was supported by walter w buckley endowment. life course approaches to the causes of health disparities relationship between chronic conditions and disability in african american men and women lagging life expectancy for black men: a public health imperative who director-general's statement on ihr emergency committee on novel coronavirus a novel coronavirus emerging in china e key questions for impact assessment differences in obesity prevalence by demographic characteristics and urbanization level among adults in the united states social class differentials in health and mortality: patterns and explanations in comparative perspective critical perspectives on racial and ethnic differences in health in late life (310e352) employee benefits in the us (bls.gov) last accessed 23 racial and ethnic disparities in health insurance coverage: dynamics of gaining and losing coverage over the life-course life or debt: underinsurance in america reducing racial inequities in health: using what we already know to take action covid-19 disparities in black americans key: cord-261907-y60yra4r authors: richardson, e. t.; malik, m. m.; darity, w. a.; mullen, a. k.; malik, m.; benton, a.; bassett, m. t.; farmer, p. e.; worden, l.; jones, j. h. title: reparations for black american descendants of persons enslaved in the u.s. and their estimated impact on sars-cov-2 transmission date: 2020-06-05 journal: medrxiv : the preprint server for health sciences doi: 10.1101/2020.06.04.20112011 sha: doc_id: 261907 cord_uid: y60yra4r background in the united states, black americans are suffering from significantly disproportionate incidence and mortality rates of covid-19. the potential for racial-justice interventions, including reparations payments, to ameliorate these disparities has not been adequately explored. methods we compared the covid-19 time-varying rt curves of relatively disparate polities in terms of social equity (south korea vs. louisiana). next, we considered a range of reproductive ratios to back-calculate the transmission rates {beta}i[->]j for 4 cells of the simplified next-generation matrix (from which r0 is calculated for structured models) for the outbreak in louisiana. lastly, we modeled the effect that monetary payments as reparations for black american descendants of persons enslaved in the u.s. would have had on pre-intervention {beta}i[->]j. results once their respective epidemics begin to propagate, louisiana displays rt values with an absolute difference of 1.3 to 2.5 compared to south korea. it also takes louisiana more than twice as long to bring rt below 1. we estimate that increased equity in transmission consistent with the benefits of a successful reparations program (reflected in the ratio {beta}b[->]b / {beta}w[->]w) could reduce r0 by 31 to 68%. discussion while there are compelling moral and historical arguments for racial injustice interventions such as reparations, our study describes potential health benefits in the form of reduced sars-cov-2 transmission risk. as we demonstrate, a restitutive program targeted towards black individuals would not only decrease covid-19 risk for recipients of the wealth redistribution; the mitigating effects would be distributed across racial groups, benefitting the population at large. the novel coronavirus which causes covid-19 was first reported in hubei province, china in december 2019. 1 in the ensuing 5 months, the outbreak spread to nearly every country in the world. 2 as of 28 may 2020, the united states had the highest number of reported cases of covid-19 with 1,698,523 confirmed infections and 100,446 total deaths 3 -although this certainly represents an underestimate of the true number of cases given the poor scale-up of testing coupled with a high rate of asymptomatic infection. 4, 5 as has been the case in previous pandemics, communities of color are suffering from disproportionate incidence and mortality rates of covid-19. 6, 7 in the states that have released data by race, this gap is notably pronounced among black americans who are dying at an ageadjusted rate that is 3.6 times as high as the rate for whites. 8 it further adds to vast disparities in black and white health that have been the cumulative result of legacies of slavery, legal segregation, white terrorism (e.g., lynchings during the jim crow period), hyperincarceration, lethal policing, and ongoing discrimination in housing, employment, policing, credit markets, and health care. [9] [10] [11] while frameworks for understanding the mechanisms through which biosocial forces become embodied as pathology are inchoate, allostatic load (the physiological profile influenced by repeated or chronic life stressors) can be used to demonstrate how the continuous trauma of oppression can lead to disparities in health by race. [12] [13] [14] [15] [16] [17] [18] [19] the potential for racial-justice interventions, including reparations payments, to ameliorate these disparities, has not been adequately explored. 20 mathematical and computational models of infectious disease transmission dynamics increasingly are being used to determine the potential impact of interventions on incidence and mortality. 21 fundamental to this work is calculation of the basic reproductive number r0, which is defined as the expected number of secondary cases caused by a typical infected individual in a fully susceptible population. 22 while r0 provides theoretical information about an epidemic, practical control ultimately depends on the expected infections generated later in the outbreak prompting epidemiologists to utilize the effective reproduction number rt (i.e., the average number of secondary cases generated by an infectious individual at time t), which obviates the assumption of a fully susceptible population and allows for the temporal dynamics to be followed in the setting of various interventions. 23 models must make assumptions about how people interact with others, 24 but they rarely account for social forces like institutional and cultural racism that structure such interactions. 25 therefore, they can obfuscate such forces in their attempts to describe outbreak transmission dynamics. [26] [27] [28] nonetheless, it is possible to incorporate risk heterogeneities into models, and to use this information to identify more just measures for disease prevention/control. [29] [30] [31] [32] [33] for example, black workers are overrepresented in front-line sectors like food service and delivery, healthcare, and child-care, which places them at higher risk of sars-cov-2 infection. furthermore, black individuals have a higher likelihood of living in dense, precarious housing where effective social distancing is hindered. these risks are structural-that is, not determined by personal choice or rational assessment, as models often assume (what koopman and longini refer to as "the erroneous attribution of individual effects" 34 ); 35,36 they could therefore benefit from structural interventions. as such, the following modeling study explores the potential effects of reparations payments on the disproportionate covid-19 risk among black people in the u.s. for a representative inegalitarian state in the u.s., we chose louisiana as a unit of analysis due to the availability of covid-19 data compiled by race. louisiana has one of the highest gini coefficients (a measure for household income distribution inequality-a value of 0 represents total income equality [all households have an equal share of income], while a value of 1 represents total income inequality [one household has all the income]) among the american states (0.5), 37 is highly segregated between black and non-black populations (supplemental table 1 ), and has significant differences in the average number of persons per room (ppr) for black and non-black populations ( figure 1 ). (ppr is a measure of overcrowding 38 that recent reports indicate might be a more important for risk of infection than urban density. 39 ) as of 28 may 2020, the state reported 38,802 sars-cov-2 infections. 40 we estimated timevarying (instantaneous) rt using the method of wallinga and teunis, 41 which uses a probability distribution for the serial interval (i.e., the time, in days, between symptom onset in an index case and symptom onset in a person infected by that index case). confidence intervals for rt were calculated using a normal approximation for the estimated number of secondary cases per case (i.e. approximating the 95% central interval by the expected value rt +/-1.96 times the standard deviation). following current best estimates of the serial interval, we chose a gamma distribution with a mean of 5 and standard deviation of 2. 42,43 all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 5, 2020. . to juxtapose these data with those reported from a relatively egalitarian polity, we conducted a similar analysis of the outbreak in south korea, 44 which in contrast to louisiana, has a gini coefficient of 0.32 45 and no large, segregated subgroup of the population composed of the descendants of enslaved persons. south korea nonetheless has 10 times the population density of louisiana such that, if density per se were the major determinant of epidemic severity, we would expect rates of infection to be much higher in the former compared to the latter, which is not the case (louisiana has reported nearly 40 times the number of cases per 100,000 people as south korea). 40, 44, 46, 47 to estimate the effect prior reparations payments may have had on the outbreak in louisiana, we considered reproductive ratios from the range of pre-intervention rt (a stay-at-home order was issued on 22 march 2020). from the theory of epidemics in structured populations, we know that all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 5, 2020. . takes louisiana more than twice as long to bring rt below 1, the critical value at which an outbreak will die out in a population (24 days vs 11). our next-generation matrix analysis shows that, in a segregated society like the u.s. where sars-cov-2 transmission rates are disproportionate across racial groups, small changes in the ratio between bb®b and bw®w can result in large changes in the reproductive ratio for the population (figure 3a) , due mainly to 1) the effects of high assortative mixing structured by racism on the value of cb®b; and 2) the fact that the expected number of secondary infections generated within high-risk subgroups (i.e., the value gb®b in the next generation matrix-in this case driven by high relative values of cb®b) comes to dominate r0 for a population. 29, 52 a program of reparations has the potential to reduce several variables that determine the covid-19 reproductive ratio in such a segregated society. these include i) reducing ci®j significantly for black people by decreasing overcrowded housing (this also has the benefit of improving an individual's ability to social distance once stay-athome orders are enacted); ii) reducing bw®b as black individuals would not be forced as frequently into high-risk frontline work-with both attendant exposure and psychosocial stress; iii) decreasing t slightly on account of people's ability to access preventive modalities like masks, hand sanitizer, etc. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 5, 2020. . accordingly, the arrow in figure 3b shows how different assumptions regarding the effects of reparations could play out: it begins within the range of r0 we selected from the louisiana outbreak pre-intervention (i.e., before the stay-at-home order was enacted); it ends within our estimates for r0 in the setting of reparations, which are consistent with early values of rt estimated for south korea and are 31 to 68% lower than pre-intervention estimates for louisiana. this is achieved by the transmission rate bb®b decreasing to near parity with bw®w, which reflects the anticipated mitigation in structural racism a successful reparations program would engender. the color line (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 5, 2020. . https://doi.org/10.1101/2020.06.04.20112011 doi: medrxiv preprint the greatest impact on the epidemic for the population at large. reducing severe inequalities is thus not simply just, it is epidemiologically efficacious for outbreak containment. in general, a program of reparations is intended to achieve three objectives: acknowledgment of a grievous injustice, redress for the injustice, and closure of the grievances held by the group subjected to the injustice. 58 2) changes in the built environment, fostering the ability to social distance; 3) spreading out of front-line work across racial groups; 4) decreased race-based allostatic load. current explanations of excess covid-19 risk for black americans focus on personal failure to follow public health advice and lifestyle choices that result in co-morbid conditions (e.g., coronary artery disease and diabetes). 59 neither, however, addresses excess exposure, which is structured by institutional racism (and captured in the parameters bi®j). indeed, reported mortality rates up to 7 times that of white populations likely reflect considerable underdiagnosis of cases in black communities, 60 rather than intrinsic differences in risk of death once infected. in other words, while there is some differential mortality by race for covid-19 (exacerbated by allostatic load), incidence is likely much higher in black communities than we appreciate. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 5, 2020. . https://doi.org/10.1101/2020.06.04.20112011 doi: medrxiv preprint contrary to the way it is often depicted popularly, r0 is not an intrinsic property of a particular pathogen (nor are mortality rates 61 ). rather, the reproduction ratio encapsulates social structure, behavior, and differential risk in a population. 62 such risk is often structural, 63 however, and modeling studies seldom capture oppressive social forces such as institutionalized racism and sexism in their emphasis on 'objective,' well-defined parameters. while some scholars attribute this to the inherent conservatism of causal reasoning, 64,65 it may be more justly described as a form of symbolic violence, referring to the ways naturalized symbols and language sustain relations of oppression. [66] [67] [68] [69] in the case of epidemic modeling, we rarely are presented with racial-justice interventions as ways of preventing and containing outbreaks. accordingly, this paper has utilized the properties of mathematical models of infectious diseases to illustrate how pandemic containment policy can go beyond the wearing of masks and stay-at-home orders: interventions in risk structure-that is, the way people are enabled or constrained in their associations with others-are crucial to pandemic preparedness, the ability to comply with containment policy once it is decreed, and racial justice in general. such an amelioration of structural risk can be achieved with reparations. since reparations have not been enacted, however, 'reopening' american society early (after coronavirus-forced shutdowns) will have a disproportionate adverse mortality effect on black people, an effect that is predictable. therefore, de facto, it resembles a modern tuskegee experiment, since massive wealth redistribution could avert these deaths, just as penicillin would have in the nearby state of alabama. 70, 71 as the apm research lab has reported, "if they had died of covid-19 at the same rate as white americans, about 13,000 black americans, 1,300 all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 5, 2020. . https://doi.org/10.1101/2020.06.04.20112011 doi: medrxiv preprint latino americans and 300 asian americans would still be alive" 60 -and this is before even 5% of the national population has been infected. the appalling evidence of racism embodied as disproportionate covid-19 incidence and mortality for black americans should add to moral, historical, and legal arguments for reparations for descendants of slaves. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 5, 2020. . https://doi.org/10.1101/2020.06.04.20112011 doi: medrxiv preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 5, 2020. world health organization. novel coronavirus -china centers for disease control and prevention. locations with confirmed covid-19 cases. 2020 centers for disease control and prevention. cases of coronavirus disease (covid-19) in the u.s. 2020 the lost month: how a failure to test blinded the u.s. to covid-19. the new york times covid-19: four-fifths of cases are asymptomatic, china figures indicate communities of color at higher risk for health and economic challenges due to covid-19 racial disparities in exposure, susceptibility, and access to health care in the us h1n1 influenza pandemic racial and ethnic disparities in population level covid-19 mortality the racial disparities of coronavirus point yet again to the need for reparations. the philadelphia inquirer improving the health of african americans in the usa: an overdue opportunity for social justice the african american petri dish infections and inequalities: the modern plagues under the skin: using theories from biology and the social sciences to explore the mechanisms behind the black-white health gap integrating biology into the study of health disparities forced removals embodied as tuberculosis structural racism and health inequities in the usa: evidence and interventions allostatic load burden and racial disparities in mortality skin color, social classification, and blood pressure in southeastern puerto rico lifetime discrimination burden, racial discrimination, and subclinical cerebrovascular disease among african americans covid-19 and the limits of public health 'science' projections of ebola outbreak size and duration with and without vaccine use in équateur, democratic republic of congo, as of a brief history of r 0 and a recipe for its calculation measurability of the epidemic reproduction number in data-driven contact networks wrong but useful -what covid-19 epidemiologic models can and cannot tell us racism and health i: pathways and scientific evidence the dialectical biologist health, human rights, and the new war on the poor on the coloniality of global public health modeling infectious diseases in humans and animals culture for epidemic models and epidemic models for culture assessing risk factors for transmission of infection individual causal models and population system models in epidemiology the ecological effects of individual exposures and nonlinear disease dynamics in populations bringing context back into epidemiology: variables and fallacies in multilevel analysis structural violence and clinical medicine american community survey briefs from here to equality: reparations for black americans in the twenty-first century emerging infections and nested martingales: the entrainment of affluent populations into the disease ecology of marginalization forty acres and a mule in the 21st century racial health disparities and covid-19 -caution and context the color of coronavirus: covid-19 deaths by race and ethnicity in the the ebola suspect's dilemma contact structure, mobility, environmental impact and behaviour: the importance of social forces to infectious disease dynamics and disease ecology an anthropology of structural violence is the "well-defined intervention assumption shackling the identification police. cambridge the sociology of pierre bourdieu six sideways reflections historicizing historical trauma theory: troubling the trans-generational transmission paradigm the symbolic violence of 'outbreak': a mixedmethods, quasi-experimental impact evaluation of social protection on ebola survivor wellbeing tuskegee and the health of black men racism and research: the case of the tuskegee syphilis study key: cord-034084-b1biu6fm authors: tolia-kelly, divya; carvalho cabral, diogo de; legg, stephen; lane, maria; thomas, nicola title: historical geographies of the 21st century: challenging our praxis date: 2020-10-21 journal: j hist geogr doi: 10.1016/j.jhg.2020.08.002 sha: doc_id: 34084 cord_uid: b1biu6fm nan historical geographies of the 21st century: challenging our praxis on the 4 th july 2020 the statue of black anti-slavery campaigner frederick douglass was torn down in rochester, new york. it celebrated douglass's campaigns against the inequality that persisted in nineteenth century us society despite constitutional commitments to liberty and fundamental rights. on the 5 th of july 1852 douglass emphasized this persistence in an address to the women of the rochester anti-slavery sewing society, regarding the anniversary of american independence: 'i say it with a sad sense of the disparity between us. i am not included within the pale of this glorious anniversary! your high independence only reveals the immeasurable distance between us. the blessings in which you, this day, rejoice, are not enjoyed in common. the rich inheritance of justice, liberty, prosperity and independence, bequeathed by your fathers, is shared by you, not by me. the sunlight that brought life and healing to you, has brought stripes and death to me. this fourth july is yours, not mine. you may rejoice, i must mourn'. 1 the destruction of douglass's statue, an 'anarchic' and likely racist act, was conducted in the context of global calls for scores of statues across the world to be torn down, in the main monuments to the great white men of commerce and colonisation. 2 the killing of 46 year old george floyd by us police in minneapolis on the 25 th june 2020 ensured an eruption of black lives matter demonstrations, rallies and gatherings mourning brutality against black bodies and the lack of human rights and civil liberties of black citizens the world over. 3 the cultural landscape inscribes the negations of black history, heritage and space and belies a fuller, inclusive memorialisation of all citizens and all humanity. public monuments to colonial governance, slavery or the values of imperial military control are daily experienced by black bodies traversing public space in bristol, washington dc, kolkata or pretoria. these commemorations of violence within landscapes of national heritage have been re-identified as monuments to erasures, violences, racisms and negations of black life, black contributions to civil society and indeed black intellectual contributions to modernity itself. the removal of douglass's statue, however, was an aggressive assertion of the status quo of the dominant whiteness of us narratives and the privileging of white histories as materially represented in heritage monuments. the space was alleviated of one of the most prominent anti-slavery voices of the us and the removal a demonstration that history could be white-washed yet again in representation, in space, in national memory and national heritage. for historical geographers witnessing the last months of protest, the long struggle of the anti-racism movement has been ever present, as evidenced by the removal of douglass's statue. many, however, have gained renewed hope that this moment will produce a critical change in the landscapes of injustice. within the last century the historical geography community has contributed to several paradigm shifts within the arts, humanities and social sciences. many are marked in the journal of historical geography. 4 we are in an age of another shift in intellectual atmosphere, a metaphorical quake calling us to rethink and revise our intellectual foundations, scholarly orientations and ethical praxis. in 2020 the changed jhg editorial team reflected and recognised the shift to decolonising the sub-discipline, recognising questions of race and racisms in scholarship, intellectual institutions, education curricula, networks, research and the economies of research posts and publications. 5 this editorial marks a cultural and political tuning-in to the risks of racial complacency and an acknowledgment of the role of race https://www.whitehouse.gov/presidential-actions/executive-orderprotecting-american-monuments-memorials-statues-combating-recent-criminalviolence/last accessed july 10, 2020. not all dialogues around public memorialisation are linked to white men, see also discussions around e.g. 'ghandhi must fall'. 3 see: the black lives matter campaign for racial justice which began as a movement to end to extra-judicial killings of black citizens in public space in the us and beyond, https://blacklivesmatter.com/last accessed 10 july 10, 2020. journal of historical geography j o u r n a l h o m e p a g e : w w w . e l s e v ie r . c o m / l o c a t e / j h g and racisms in shaping disciplinary and academic practices and publications. the editorial team are currently in the process of reviewing the publication cultures and practices associated with the journal. this review responds to the directional change signalled by the jhg editorial board and publisher's ways of enlivening, elaborating and extending its methods and boundaries of work through the appointment of an expanded editorial team. we are currently working with a discussion document that asks the team to reconsider every element of jhg's existing spheres of engagement, and to also imagine how the journal should work for the broadest community of historical geography. this includes being conscious of potential prejudicial practice, and the effects of the values and inheritances of imperial and colonial paradigms of thought that are skewed towards a particular geopolitical hierarchy of what, who, and where, counts as sites of production for valuable historical geographical scholarship. our institutional structures of being are embedded with praxis which may effectively marginalise, annihilate or indeed diminish an international ethos to valuing scholarship and including scholarship from all corners of global historical geographical research. the team have witnessed how this has shaped the journal as we review the country of origin data of author location when publishing in the journal. the majority of jhg authors reside in uk, north america and europe, of the 157 authors published in the journal in the last 5 years, only 3 authors had positions in brazil and mexico, 2 in china, 4 in israel. 6 while this imbalance is indicative of the anglo-american history of the sub-discipline, it by no means reflects the balance of the contemporary international community who attend conferences such as the international conference of historical geography. it also does not reflect the wide diversity of authors' countries of origin who submit papers for review. embedded in our current journal review process is a call to arms to re-evaluate the presence of (and perhaps unintended parameters of) blocs, institutional borders, obstacles and exclusionary habits of editorial and reviewer praxis. we are in the process of understanding what the form of a strategic culture change will look like. one which propels us towards a mindful practice that goes beyond the usual assumed grammars and performances of practice in academic publishing. we are working with this as a mindful, antiracist, inclusive approach which works through how we work with, and ultimately shed the risks of practices that present as perhaps unconsciously anachronistic and ultimately antiintellectual in their habits and myopic tendencies. the editorial team are working with current submissions to the journal testing our emerging collective editorial manifesto. what does it mean in practice to embrace an explicit, anti-racist agenda that recognises, structural, systemic, conscious and subconscious bias on the grounds of race, ethnicity, culture and geopolitical location? reviewers are being asked to look at some papers that might previously have been returned to the author with a desk-based rejection as the editorial team address the gate-keeping challenges of this decolonising process. we are thinking through ways of supporting authors to have positive review experiences by giving greater editorial feedback before sending out to review. this often entails formally 'rejecting' an author's work as demanded by the elsevier editorial management system, but writing to the author with detailed instructions which will support the development of their article, with an invitation to resubmit. these are practices which were seeded within the previous practice of jhg editors, but are now essential if we are to support an anti-racist editorial praxis. the jhg/british academy sponsored writing workshops for scholars in latin america is a more proactive programme of work which enables us to co-learn how to work with authors in regions which are poorly represented in the journal. this programme is being re-shaped as a result of covid-19 restrictions, but in being reshaped, promises to open out a virtual platform that will have more reach and depth for the wider international community of historical geographers. this editorial approach is looking to take a step beyond assumptions about already being 'good professional practitioners' to embodying anti-racist values and becoming anti-racist activists within the discipline and parameters of a journal of historical geography. this shift is not simply about the positive discrimination towards representation of others but about creating an arena for a fully enfranchised historical geographical community that recognises the evidence that we do not have recognition of all the historical scholarship that is rightfully situated within our disciplinary economies of knowledge production, exchange, intellectual reflection and higher education populations. there continue to be obstacles to 'international' scholarship that includes scholars both within and without the spectrum of historical geography as is currently constituted. geographically, intellectually and morally beyond reaffirming the familiar well-worn geographies of knowledge exchange between nodal points (and related bodies) in europe and north america. 7 the editorial team have sought to clearly outline what benefits and 'to what end' this shift towards a decolonising and anti-racist praxis serves. what is hoped for is an expansion of the notion of practicing inclusive scholarship, towards building bridges for a fuller and more comprehensive participation of the 'others' within and beyond the usual grammars, archives, and moral geographies of historical geography publication. it is not the case, as is often cited, that moves towards inclusivity in the constituency of the jhg automatically ensures a rupture with a commitment to quality and excellence in scholarship, but that we attentively seek to learn from subaltern historiographies, and treat knowledge production as internationally present and dialogic. 8 we engage debates about epistemic justice, in terms of what has delineated accounts of what are 'credible historical geographies' and who are considered 'credible historical geographers'. in 2002, peake and kobayashi argued succinctly for a shift in academic culture towards an antiracist geography. 'as we enter the new millennium, geographers have a momentous opportunity to reflect upon the historical development of our discipline and the academic culture within which it thrives, with the aim of setting out an antiracist agenda. we advocate a fundamental refashioning of the discipline… (o)ur agenda for antiracist geography also involves three aspects of institutional change: to build up on and extend traditional geographical scholarship; to change the basis of the discipline by extending the principles of antiracism throughout our institutional practices, particularly in the classroom; and to change the face of the discipline by increasing the participation and contributions of geographers of color. '. 9 this call reflects much of the shift envisaged by the new editorial team and their individual portfolios hope to express some of the practices that may help to actualise change, improvement and material effects in producing a radical anti-racist template in academic journal publications. as ruth gilmore wilson has argued (2002), a radical awareness and acknowledgment of 'the fatal couplings of power and difference signified by racism… demands examination of the subjective and objective nature of power and difference as articulated and naturalized through racism; one can follow the reasoning, and adjust the methods, for studying interrelated fatalities. in other words, we must change aspects of both the forces and the relations of knowledge production in order to produce new and useful knowledges.'. 10 these acknowledgements of power and difference are reaffirmed in the circulation of an email to editors from jhg's publisher, elsevier, on july 3rd , 2020. in the spirit of the responses to the black lives matter movement, elsevier have firstly called upon editors to reflect on the goal of '(r)aising the participation of women and individuals from underrepresented racial/ethnic minority groups on editorial boards and as editors, reviewers and authors'. secondly, they are '(p)roviding and developing additional resources to assist editorial teams to assist with incorporating greater diversity, inclusion and equality in your journal'. and thirdly they are '(d)eveloping opportunities and resources for you to engage in productive discussion about inclusion & diversity issues and actions across the research community'. 11 these outline the fact that diversity and inclusion are fundamental to the futures of commercial academic publishing, as much as any other public institution. the lens is on those systemically outside, at the edge or indeed unconsciously 'lost' to research publication. we are left searching for the figures of historical geography that are outside the core, at perhaps the margins, or to be found in spaces where historical geography scholarship has flourished within a different disciplinary homes. 12 the jhg editorial collective purposefully brings a team of people together with skills, knowledge and experience of diverse and divergent scholarship and praxis. the team's asynchronous dialogues around this editorial and wider journal review reveal the gaps, fissures and flaws as we work towards a praxis that 'fits' with the politics and struggles for inclusion experienced by authors located in, for example, latin america, india and africa. we have considered the ways in which our thinking continues to cause epistemic violence, and how we (inadvertently) continue to silence or misrepresent alterities by narrowing a focus to a specific intellectual movement or region. we see the future space of the journal as a site where the questions we can been asking ourselves might be reviewed. how do we think about the overlaps but differences between the decolonial movement and the various issues and campaigns circulating around black lives matter? how do these movements themselves intersect with longer established traditions such as postcolonialism, subaltern studies and black history? what geographies are at play here, for example the dialogues within central/south american and asian engagements with blm compared to decolonial agendas? how do these questions, seemingly focusing on urban, social and cultural questions in historical geography, also intersect across environmental, ecological and physical geographical realms? this editorial is a signal that we welcome and hope to contribute to this dialogue. to offer an invitation to the community, we focus the final section of this editorial as a reflection on the intersection of our new jhg editorial manifesto with the black lives matter movement. decolonising the academy and publication is doing more than including 'black' historical geography, but as a starting point, let us see what this partial figure would look like. at the heart of the current black lives matter movements (and their connected constituents advocating for a decolonising of the academy) is a challenge to the systemic, daily annihilation of black citizenry; in body, spirit, mind, space and the economies of everyday life. the figure of black however is dynamic, shifting historically, politically and culturally, a point that cedric robinson makes so powerfully in black marxism. 13 this shifting account of what we are 'saving' leaves the door constantly open to challenge from those that oppose the recognition of racisms in daily life including academia. who are we claiming ground for? and how do we justify opening the door, if it, in a meritocracy, it has always been ajar? this leaves us with an inherent political problem as articulated by stuart hall: 'the fact is that 'black' has never been just there either. it has always been an unstable identity physically, culturally and politically. it, too is a narrative, a story, a history … black is an identity which had to be learned in a certain moment.'. 14 in this moment, the identity of 'black' scholarship is a political positioning of scholarship identified as other to core of academic cultures, or what can be considered academic mainstream in historical geography. it is a moment where self-determined accounts of what is, can be and what futures historical geography could look like, embody a sensibility of democratic access to the community. 'black' scholarship is a political identification of knowledge production of research that is considered sitting outside 'the centre' of intellectual righteousness, or that which is yet to find an intellectual seat at the table, or that which is deemed 'uncultured', 'uninviteable' simply because of the geography of production, or the language of thought from which research emerges. there is much 'black' historical geographical research already making that which is negated, present, most notably in the work of caroline bressey. 15 but there is much ground, space and research space still to cover. in response to this the jhg editorial collective's responsibility as we review the journal is to ensure that the praxis we champion does not close, but enables a flourishing culture of radical, international dialogue which might be uncomfortable, challenging, 10 r.w. gilmore, fatal couplings of power and difference: notes on racism and ge-different in tone, presentation, style and content. we have started this process with a commissioned response by lara choksey reflecting on the removal of the statue of slave owner edward colston in bristol uk, june 2020. this will soon appear in the historical geography at large section of jhg and marks the shift which we are hoping to deepen. needless to say, it will be our collective responsibility, as a community of editors, reviewers, authors and readers to shape this culture. we hope as an editorial collective we will put in place a praxis that opens up new norms which enables broader constituencies to find their home in the journal. editor briefings: in support of equity, inclusion and diversity the making of the black radical tradition the real me: postmodernism and the question of identity forgotten histories: three stories of black girls from barnardo's victorian archive. women's history review ) 47e61; c. bressey, it's only political correctnesserace and racism in british history key: cord-031396-cb97rcbk authors: saratha, s. r.; sai sundara krishnan, g.; bagyalakshmi, m.; lim, chee peng title: solving black–scholes equations using fractional generalized homotopy analysis method date: 2020-09-04 journal: comp doi: 10.1007/s40314-020-01306-4 sha: doc_id: 31396 cord_uid: cb97rcbk this paper aims to solve the black–scholes (b–s) model for the european options pricing problem using a hybrid method called fractional generalized homotopy analysis method (fgham). the convergence region of the b–s model solutions are clearly identified using h-curve and the closed form series solutions are produced using fgham. to verify the convergence of the proposed series solutions, sequence of errors are obtained by estimating the deviation between the exact solution and the series solution, which is increased in number of terms in the series. the convergence of sequence of errors is verified using the convergence criteria and the results are graphically illustrated. moreover, the fgham approach has overcome the difficulties of applying multiple integration and differentiation procedures while obtaining the solution using well-established methods such as homotopy analysis method and homotopy perturbation method. the computational efficiency of the proposed method is analyzed using a comparative study. the advantage of the proposed method is shown with a numerical example using the comparative study between fgham and monte carlo simulation. using the numerical example, analytical expression for the implied volatility is derived and the non-local behavior is studied for the various values of the fractional parameter. the results of fgham are statistically validated with the exact solution and the other existing computational methods. european option valuation under transaction costs. section 5 presents an analysis of the non-linear generalized fractional b-s equation governing european option valuation under transaction costs. section 6 presents an analysis of fractional b-s option pricing equation and also compares with monte carlo simulation. section 7 validates the statistical analysis for the above numerical examples. section 8 draws the concluding remarks and presents the suggestions for future research. this section discusses some basic definitions of fractional calculus used in this study. definition 2.1 the riemann-liovillie fractional integrals (samko et al. 1993 ) of the left and right sides are defined for any function φ(x) ∈ l 1 (a, b) as: definition 2.2 the riemann integral on the half axis (samko et al. 1993) subjects to a variable limit which can be expressed as: the left-and right-handed riemann-liouville fractional derivatives (samko et al. 1993 ) of order α, 0 < α < 1, in the interval [a, b] are defined as: definition 2.4 the caputo fractional derivative of order α is defined as: definition 2.5 the mittag-leffler function, which is a generalization of the exponential function, is defined as: where α ∈ c, r(α) > 0. the continuous function f : r → r, t → f (t) has a fractional derivative of order kα. for any positive integer k and for any α, 0 < α < 1, the taylor series of fractional order is given by: where (1 + αk) = (αk)! . , y(0) = 0 is given by: this section introduces the fractional g-transform and discusses some of the properties proposed by saratha et al. (2020) . definition 2.7 let g(t) be any time-domain function defined for t > 0. then, the fractional g-transform of order α of g(t) is denoted by g α [g(t) ] and is defined as: where e α is the mittag-leffler function. the fractional g-transform satisfies the following properties: if the fractional-order laplace transform of a function g(t) is l α {g(t)} = f α (s), then the fractional g-transform of order α of g(t) is: theorem 2.2 (scaling property) if g α [g(t)] = h α (u), then: where a is a non-zero constant. theorem 2.3 if g α [g(t)] = h α (u), then: theorem 2.4 if g α [g(t)] = h α (u), then: the systematic procedure for the fgham (saratha et al. 2020 ) is given in the next section. consider a fractional time non-linear partial differential equation with the following initial condition: where d α is the fractional differential operator d α = ∂ α ∂t α , r is the linear differential operator , n is the non-linear differential operator, and g(x, t) is the source term. the following systematic procedure steps are used to solve the non-linear fractional differential equations: step 1: using fractional g-transform, eq. (3.1) is transformed to: (3.2) step 2: applying the derivative property of fractional g-transform, eq. (3.2) is expressed as: step 3: decomposing the non-linear terms in eq. (3.3), the following homotopy is constructed: where s ∈ [0, 1] is an embedding parameter and φ(x, t; s) is a real function of x, t, and s, while h is a non-zero auxiliary parameter, h (x, t) = 0 is an auxiliary function, v 0 (x, t) is an initial guess of v(x, t), and φ(x, t; s) is an unknown function. equation (3.4) is called the zeroth-order deformation equation. in (3.4), if s = 0 and s = 1, then φ(x, t, 0) = v 0 (x, t) and φ(x, t, 1) = v(x, t), respectively. if s ∈ [0, 1], then the solution is transferred from v 0 (x, t) to v(x, t). step 4: deriving the n th -order deformation equation in (3.5) as in (liao 1992) : (3.5) step 5: using the inverse g-transform on both the sides of eq. (3.5), the following equation is obtained: (3.7) and χ n = 0 n ≤ 1 1 n > 1. step 6: the following solution is obtained: (3.8) it is essential to evaluate the convergence of the series solution obtained in eq. (3.8) by fgham as in bagyalakshmi et al. (2016) . the approximate solution of (3.1) is obtained as v app(k) (x, t) = k n=0 v n (x, t) from (3.8) by truncating the terms for n = k + 1, k + 2, . . . ∞. then, the exact solution of eq. (3.1) is represented as: where ev k (x, t) is the error function. generally, the absolute error is defined as ev k ( to establish convergence of equation (3.8), it is necessary to show that the sequence ev k (x, t) is a convergent sequence. since the sequence is bounded below, it is sufficient to prove that the sequence ev k (x, t) is monotonically decreasing. as such, the convergence criteria are ev k (x,t) < 1 for k < p. using the following algorithm, convergence of the iterative solution v app(k) (x, t) to the exact solution v(x, t) is shown below: the following section solves the fractional b-s equation and generalized fractional b-s equation using fgham. the obtained solutions are compared with those of the exact solution along with statistical validation. the results indicate an excellent agreement with some existing methods. considering the fractional b-s equation: with the initial condition: v(x, 0) = max(e x − 1, 0). equation (4.1) contains parameter k = 2r σ 2 , where k represents a balance between the interest rate and variability of stock returns, with the dimensionless time to expiry σ 2 2t . the other four dimensionless parameters are the exercise price e, expiry t , volatility of the underlying asset σ 2 , and risk-free interest rate r as in the original problem. applying the fractional g-transform on both the sides of eq. (4.1): solving the above equation for n = 1, 2, 3, . . .: similarly, v 4 , v 5 , . . . are estimated and the series solution is obtained, that is: if h = −1, eq. (4.2) can be expressed as: table 1 shows the absolute errors subject to some particular points α = 1 and x = 0.5. this proves the convergence of the series solution of (4.1). figure 1 depicts a comparison of the absolute errors for the different sequences of partial sums. the convergence region is obtained using the h-curve. figure 2 shows the convergence region of eq. (4.1) between − 2 and 1. figure figure 5 depicts the financial pricing derivatives subjects to the different settings of the fractional parameter α = 0.25, 0.5, 0.75 and 1. table 2 provides the pricing option derivatives using the fractional parameter α = 1, which depicts a good agreement with the results of fgham, exact solution, rps, and cfadm, respectively. table 3 and 4 provide the pricing option derivatives using the fractional parameter α = 0.75, α = 0.5, and depict a good agreement with the results of fgham, mfdtm, rps, and cfadm, respectively. case 2. consider the vanilla call option (company et al. 2008 ) with parameter σ = 0.2, r = 0.01,α = 1, τ = 1 year, then k = 5. the solution of equation (4.6) is obtained as: (4.6) equation (4.6) is the exact solution for the given equation. table 5 shows the absolute errors with respect to some particular points α = 1 and x = 1. this proves the convergence of the series solution of (4.1). figure 6 shows a comparison of the approximate absolute errors subject to the different sequences of partial sums. the convergence region is obtained using the h-curve. figure 7 shows that the convergence region of eq. (4.1) is between − 2 and 2. figure 8 indicates that the fgham results almost coincide with those of ham, hpm, mfdtm, rps, cfadm, and the exact solution for the b-s equation. figure 9 illustrates the solution for the b-s equation subject to the various settings of the fractional parameter α = 0.25, 0.5, 0.75, 1,. figures 10 depicts the financial pricing derivatives for the different settings of the fractional parameter α = 0.25, 0.5, 0.75 and 1, respectively. table 6 provides the pricing option derivatives using fractional parameter α = 1, depicts a good agreement among the results of fgham, the exact solution, rps, and cfadm respectively. tables 7 and 8 provide the pricing option derivatives using fractional parameter α = 0.75, α = 0.5, and depict a good agreement among the results of fgham, mfdtm, rps, and cfadm, respectively. the implied volatility, an important financial parameter, which plays a vital role in pricing option problem. generally, due to the mathematical structure of the integer order b-s formula, table 2 comparison of the results for the b-s equation using the fractional parameter table 3 comparison of the results for the b-s equation using the fractional parameter table 4 comparison of the results for the b-s equation using the fractional parameter the analytical expression to estimate the implied volatility cannot be obtained in the closed form. however, it is worth to mention that the presence of fractional parameter α in the fractional b-s mathematical model has an advantage of memory-less property. thus, the non-local behavior of the implied volatility in terms of option can be analytically estimated in the closed form for the various values of the fractional parameter α. comparison of the results for the b-s equation using fractional parameter comparison of the results for the b-s equation using fractional parameter the implied volatility function σ (x, t) with respect to the fractional parameter α is denoted by σ α (x, t) and can be derived from (4.1) as shown below: (dadachanji 2015) . (4.7) using eq. (4.7), the implied volatility σ α is estimated for the various values of fractional parameter α and the results are shown in tables 9 and 10. even though the implied volatility is assumed to be a constant, the observation from the tables 9 and 10 clearly reveals the pre-local change in the implied volatility. this result illustrates the importance of the fractional-order b-s model over the integer order in analyzing the non-local behavior of the implied volatility. even though the b-s model is considered with the constant volatility due to the presence of the fractional parameter α, the non-local behavior of implied volatility [α ∈ (0, 1)] is observed and the results are presented in tables 9 and 10. considering the following generalized b-s equation: applying the fractional g-transform on both the sides of eq. (5.1): solving the above equation for n = 1, 2, 3, . . . similarly, v 4 , v 5 , . . . are estimated and the series solution is obtained as÷: table 11 shows the absolute errors with respect to some particular points α = 1 and x = 5. this proves the convergence of series solution of eq. (5.1). figure 11 depicts a comparison of the approximate absolute errors subject to the different sequence of the partial sums. the convergence region is obtained using the h-curve. figure 12 shows that the convergence region of equation (4.1) is between -2 and 2. figure 13 indicates that the fgham results coincide with those of ham, hpm, mfdtm, rps, cfadm, and the exact solution v(x, t) of the b-s equation. figure 14 illustrates the solution v(x, t) for the b-s equation subject to the various settings of the fractional parameter α = 0.25, 0.5, 0.75, 1, respectively. figure 15 depicts the information on the financial pricing derivatives using different settings of the fractional parameter α = 0.25, 0.5, 0.75 and 1, respectively. table 12 provides the pricing option derivatives using fractional parameter α = 1, which depicts a good agreement among the results of fgham, the exact solution, rps, and cfadm, respectively. tables 13 and 14 provide the pricing option derivatives subject to the fractional parameter α = 0.75, α = 0.5, which depict a good agreement among the results of fgham, mfdtm, rps, and cfadm, respectively. considering the following fractional black-scholes option pricing equation: subject to the initial condition: v(x, 0) = max (ax − b, 0) . applying the fractional g-transform on both the sides of the equation (6.1): comparison of the results for the b-s equation using fractional parameter comparison of results for the b-s equation using fractional parameter comparison of the results for the b-s equation using the fractional parameter solving the above equation for n = 1, 2, 3, . . similarly, v 4 , v 5 , . . . are estimated and the series solution is obtained as: if h = −1, eq. (6.2) can be expressed as: ] + · · · (6.3) the convergence region is obtained using the h-curve. figure 16 shows that the convergence region of equation is between − 4 and 1. figure 17 indicates that the solution v(x, t) for the b-s equation subject to the various settings of the fractional parameter α = 0.25, 0.5, 0.75 and 1, respectively. figure 18 depicts the financial pricing derivatives for the different settings of the fractional parameter α = 0.25, 0.5, 0.75 and 1, respectively. to verify the accuracy of the proposed method, the numerical results of the call option obtained using fgham for α = 1 which is compared with the results estimated using monte carlo simulation (matlab) and the results are shown in table 15 . from table 15 , it is evident that the numerical results obtained by fgham show an excellent agreement with the results estimated using monte carlo simulation. the statistical significance pertaining to the difference among the mean results obtained by fgham, exact solution, rps, and cfadm for the b-s equation using fractional parameter the fgham approach has been successfully applied to solve the fractional non-linear b-s equation governing european option pricing. using various plots of h-curves, convergence region of the solution is identified and closed form series solutions are obtained using mittag-leffler function, which clearly reveals the financial process. the suitable converciency of the proposed method is verified. the analytical expression for the implied volatility is derived and the non-local behavior is studied for the various values of the fractional parameter. the statistical analysis has been carried out using the solutions obtained from the various methods to ascertain the effectiveness of the fgham approach and to tackle the b-s pricing model in financial studies. from the experimental analysis, it is evident that the proposed method accurately predicts the solution of the b-s model. the application of fgham can be extended to solve the b-s model with the time variable coefficients to analyze the financial process in future. moreover, fgham can be applied to solve different problems, such as the navier-stokes equation, epidemic models, and pandemic model like covid-19. the application of fgham can also be extended to analyze complicated non-linear differential equations and fractional differential equations that arise in different fields of science and engineering. explicit solution to predict the temperature distribution and exit temperatures in a heat exchanger using differential transform method numerical solution of linear and nonlinear black-scholes option pricing equations derivation of the local volatility function, fx barrier options: a comprehensive guide for industry quants. applied quantitative finance homotopy perturbation method for fractional black-scholes european option pricing equations using sumudu transform a new version of black-scholes equation presented by time-fractional derivative 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fractional operator publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-295693-45etqt72 authors: mcclure, elizabeth s; vasudevan, pavithra; bailey, zinzi; patel, snehal; robinson, whitney r title: racial capitalism within public health: how occupational settings drive covid-19 disparities date: 2020-07-03 journal: am j epidemiol doi: 10.1093/aje/kwaa126 sha: doc_id: 295693 cord_uid: 45etqt72 epidemiology of the u.s. covid-19 outbreak focuses on individuals’ biology and behaviors, despite centrality of occupational environments in the viral spread. this demonstrates collusion between epidemiology and racial capitalism because it obscures structural influences, absolving industries of responsibility for worker safety. in an empirical example, we analyze economic implications of race-based metrics widely used in occupational epidemiology. in the u.s., white adults have better average lung function and worse hearing than black adults. both impaired lung function and hearing are criteria for worker’s compensation, which is ultimately paid by industry. compensation for respiratory injury is determined using a race-specific algorithm. for hearing, there is no race adjustment. selective use of race-specific algorithms for workers’ compensation reduces industries’ liability for worker health, illustrating racial capitalism operating within public health. widespread and unexamined belief in inherent physiological inferiority of black americans perpetuates systems that limit industry payouts for workplace injuries. we see a parallel in the epidemiology of covid-19 disparities. we tell stories of industries implicated in the outbreak and review how they exemplify racial capitalism. we call on public health professionals to: critically evaluate who is served and neglected by data analysis; and center structural determinants of health in etiological evaluation. "mr. floyd is over six feet tall and weighs more than 200 pounds... floyd had underlying health conditions including coronary heart disease and hypertensive heart disease. the combined effects of mr. floyd being restrained by police, his underlying health conditions and any potential intoxicants in his system likely contributed to his death." --criminal complaint against derek chauvin by the state of minnesota, hennepin county, may 29, 2020 (1) "… [t]he manner of mr. floyd's death was caused by asphyxia due to neck and back compression…. sustained pressure on the right side of mr. floyd's carotid artery impeded blood flow to the brain, and weight on his back impeded his ability to breathe… '[h]e would be alive today if not from the pressure applied to his neck by fired officer derek chauvin and the strain on his body from two additional officers kneeling on him'." --benjamin crump, esq. "independent medical examiners determined #georgefloyd's death was due to asphyxia from sustained forceful pressure. full statement:" jun 1, 2020 (2) the racialized use of individual-level risk factors is starkly evident in the aftermath of george floyd's recent murder. we see how scientific evidence is used to attribute risk to floyd's individual biology, in the form of the now familiar racial refrain of "underlying health conditions," as well as risky behavior on the part of the deceased whose physiological response to physical violence is presumed to have involved "potential intoxicants," shifting the cause of death away from police violence. the same racialized narrative is prominent in the medical literature on covid-19. the attribution of increased acquisition risk to individual-level etiologiesincluding higher rates of comorbidities and socio-cultural differences such as health-seeking behavior and intergenerational cohabitation (3)overshadow differential transmission related to structural factors (4), in particular, work environments. in this commentary, we tell stories about illness and work. we argue that the most salient commonality among exacerbates covid-19 risk for these worker populations, through replication of historical inequities and state-supported corporate neglect of worker protection (5, 6) . moreover, we argue that epidemiology as a discipline has selectively produced and promoted quantitative findings to justify and further this system of racial capitalism. the inequities evident in the ongoing covid-19 pandemic offer an opportunity to redress our role in producing racially disparate health outcomes. how does epidemiology support the interests of racial capitalism? in her scholarship on the history of race and medicine, dr. dorothy roberts describes how focusing on "underlying" health conditions and behavioral risk factors allows society "[a] to ignore how disease is caused by political inequality and [b] to justify an unequal system by pointing to the inherent racial difference that disease supposedly reveals" (20) . under racial capitalism, attention is drawn away from workplace hazards by arguing that workers are inherently at high risk of ill health due to their own racial and behavioral susceptibilities, masking and justifying how labor is structured to concentrate risky, lowwage work among non-white or otherwise marginalized workforces. contemporary, "mainstream" epidemiology's technocratic focus on individual-level biological and behavioral risk factors (21) (22) (23) readily supplies data used to justify high levels of ill health observed among of low-wage workers. in particular, "mainstream" epidemiology colludes with racial capitalism by producing disproportionately more work documenting individual-level susceptibility than it does investigating more plausible alternative workplace-level explanations for workforce disparities (22) . moreover, as we demonstrate in the empirical case study below, much of "mainstream" work in epidemiology is structurally racist in that it serves to reinforce and, post hoc, justify pervasive narratives of biological and cultural inferiority of black and brown people (24) . the collusion of epidemiology with racial capitalism is particularly insidious because racial capitalism can leverage statistical methodology that is perceived as objective to hide even obviously racist distributions of health (25, 26) . below we present an example from occupational health that demonstrates how epidemiologic data is strategically used to downplay the effects of occupational exposures on poor health and thus minimize financial exposure of the corresponding industries. lung function and hearing loss are metrics commonly monitored in manufacturing industries due to occupational safety and health administration (osha) regulations (27, 28) . these metrics are proxies of health impacts of hazardous work environments in manufacturing settings (29) . moreover, lung impairment and hearing loss are frequent grounds for workers' compensation claims (30) . workers' compensation is a legal process in which workers file claims in relation to illness and injury resulting from job tasks and exposures. compensation is paid by industry when the court rules in favor of the worker (30) . therefore, strategies that minimize identification of worker injuries directly benefit the owners of and investors in the businesses employing those workers. in the united states, on average, black adults tend to have worse lung function but better hearing than white adults (31, 32) . seminal epidemiologic analyses of the national health and nutrition examination survey (nhanes) iii (1988-1994) concluded that lung function among "african-americans" is 12-15% lower than among "caucasians" (31) . the epidemiologic data indicate the opposite for hearing. numerous u.s. cohort studies, have concluded that black adults tend to have better hearing than white adults (and females tend to have better hearing than males) (32) (33) (34) (35) . epidemiologic studies suggest that the minimum noise levels must be 25 to 45 percent louder to be detected by white americans compared to black americans (34, 36) . workers qualify for compensation only when they reach a set level of impairment. for lung function, workers are typically eligible for compensation when their lung capacity performance is lower than 90% of their predicted lung capacity. a similar time period to the niosh data. we restricted the sample to respondents aged 20 to 65 years who reported "ever having job exposure to loud noise" (40) . we estimated the percent of workers who meet the respective thresholds for a disability claim under two conditions: (1) the current standard and (2) a counterfactual scenario in which race adjustments were (hearing) or were not (lung function) used. for the counterfactual hearing loss condition, we applied a conservative 25% decrement to white workers, based on age-adjusted population estimates (34, 36) . for the counterfactual lung function condition, we eliminated the race correction from the predicted lung function equation. using the current algorithms for predicted lung function, 60% of white workers and 81% of black workers' qualify for compensation. when applying an algorithm to black workers that is not race corrected, 94% of the black workers would qualify for compensation. using the current, non-race corrected algorithm for predicted hearing, 43% of white workers and 70% of black workers would qualify for compensation. when imposing a race-specific adjustment for white workers, only 38% of white workers would qualify. in all four scenarios in figure 1 our analysis of workers' compensation claims makes explicit one mechanism by which racial capitalism enriches industries. in the counterfactual scenario of no black lung function correction but a white hearing correction, industry would owe 31% more in worker's compensation payouts (this calculation is based on applying the average payout associated with each workers' compensation award in a typical state (30)). of course, applying a black race correction to lung function and a white race correction to hearing would theoretically reduce industry payouts even more. so why are race corrections for lung function uncontested, standard practice in occupational regulations and occupational epidemiology research (37, 41) , while race corrections for hearing are not? first, as shown by the 31% statistic above, the black race correction is more profitable to industry than a white race correction. under racial capitalism, black workers experience more work-related health damage because they are concentrated in riskier, less protected jobs. therefore, "corrections" that understate the extent of their damaged health will be disproportionately more valuable to industry than corrections that understate workplace impacts on less exposed populations. second, consistent applications of race corrections would undermine the narrative of inherent black biological inferiority that helps make racial capitalism so profitable. exposing the fact that black workers in high-noise jobs experience more hearing impairment even though a race correction is applied to account for the typically worse hearing of white adults makes more obvious the likelihood that the greater hearing damage observed among black workers is actually because of the workplace setting. that logical connection in turn suggests that other health harms disproportionately experienced by black workers are also because of the organization of work. we end this section with a note about epidemiology's complicity with racial capitalism in regard to damage to hearing and lung function. as we've described above, the field of epidemiology has published and promoted the use of race-"corrected" equations for whatever the intentions of these analytic and dissemination decisions, the overall impact of this body of epidemiologic research is to reinforce a narrative of black workers' biological inferiority, increasing the financial gains that industries can reap by using racial capitalism as an organizational strategy. next we briefly discuss key industries implicated in the spread of the sars-cov-2 virus in the u.s. we group the work settings by the demographic compositions of the workers or the clientele served. applying theories of racial capitalism and inverse hazard law, we argue that the risks associated with these workplaces are highly patterned by race/ethnicity and immigrant status. from farmworkers to meatpackers to supermarket chain employees and food delivery workers, the extreme vulnerability of labor forces across the food production system demonstrates that while industrial agriculture work is considered essential, the workers themselves are treated as expendable (14) . moreover, the concentration of u.s. the construction industry employs nearly 7 million workers with an estimated 14% of construction workers being undocumented, though this is likely an underestimate. austin, texas, is home to an estimated 50,000 construction workers, about 50% of whom are undocumented and more than 50% of whom make below poverty-level wages (46) (47) (48) . despite early orders by local government declaring construction workers "non-essential" and subject to stay-at-home orders (49) , and despite an epidemiologic study identifying significant risk of hospitalization from covid-19 if construction workers were to resume work (50) , under the influence of building and real estate industries the state governor quickly intervened with a statewide order deeming all construction work as "essential" (51) . by early april it was clear that construction workers, latinx workers in particular, were falling sick and being hospitalized from covid-19 at disproportionately higher rates than the general public (51) (52) (53) . the majority of cluster cases in austin were linked to construction work sites and surveillance testing for coronavirus among construction workers yielded a positive rate of approximately 3.5 times the average rate at drive-through surveillance sites (54) . the flawed dominant narrative blames workers in this industry by attributing high disease transmission to multigenerational households, inadequate personal hygiene and poor health literacy (55) . however, despite city-wide requirements for construction employers to support strict physical distancing guidelines and personal hygiene recommendations, no oversight mechanism exists and workers report ongoing lack of access to personal protective equipment (56) . carceral facilities differ from the other workplaces described above in that a predominantly white workforce oversees a disproportionately black and latinx population (72) . we include these facilities here because jails, prisons, and ice detention centers are major sites of sars-cov-2 transmission (73) (74) (75) . we recognize that the disparities in incidence and mortality related to covid-19 stem from centuries of u.s. industrial development which depends on structural racism to thrive (7). our analyses have salience beyond the scope of this outbreak. as with all diseases for which workplace environment is a root cause, the most marginalized workers with the least power and resources (e.g. undocumented residents, incarcerated individuals, people of color, women, lgbtq individuals) are least likely to have access to testing for infectious diseases and most likely to be missed in cohort enumeration (17) . during the covid-19 outbreak, public health institutions are not collecting and/or suppressing complete testing, workplace, and demographic information (12, 79) . despiteor perhaps because ofunderlying risks, decision-makers have been reluctant to release data regarding covid-19 cases, deaths, and hospitalizations associated with nursing homes, with some going as far as insinuating it was "bad for business" (80, 81) . at minimum, all covid-19 researchers in the u.s. should routinely collect data on occupation and stratify data summaries by race, ethnicity, and gender whenever possible. at the least, we must strive toward a field of inquiry in which political influence does not compromise public health practice. we urge covid-19 researchers and public health professionals more broadly to engage with occupational hazards as root causes of diseases and disparities. one of epidemiology's founding legends is john snow's removal of the broad street pump (82) . would we be talking reverentially about john snow if he'd done a study of individual-level risk factors for cholera death among those admitted to the regional hospital? ford and airhihenbuwa's public health critical race praxis calls on public health professionals to question the ways in which we recreate racism through our study designs, information collection, research questions, and data analysis methods (83) . by ignoring and misrepresenting root causes of poor health among workers, we absolve industries and government leaders of their responsibility for equitable health protection. in the midst of the covid-19 crisis, we have an opportunity to critically evaluate our methods and take measurable steps toward promoting social justice and health equity. independent medical examiners determined #georgefloyd's death was due to asphyxia from sustained forceful pressure ethnicity and covid-19: an urgent public health research priority. the lancet racism and the political economy of covid-19: will we continue to resurrect the past? abolition in the time of covid-19. antipode online [electronic article racial capitalism: a fundamental cause of novel coronavirus (covid-19) pandemic inequities in the united states black marxism : the making of the black radical tradition environmental racism, racial capitalism and state-sanctioned violence understanding covid-19 risks and vulnerabilities among black communities in america: the lethal force of syndemics employed persons by detailed industry, sex, race, and hispanic or latino ethnicity coronavirus guidelines for america indigenous groups are taking on governments over coronavirus failures work-based risks to latino workers and their families from covid-19 | econofact unequally vulnerable: a food justice approach to racial disparities in covid-19 cases covid-19 in racial and ethnic minority groups physicians' risk from covid-19: a reassuring statistic the inverse hazard law: blood pressure, sexual harassment, racial discrimination, workplace abuse and occupational exposures in us low-income black, white and latino workers world health organization. rational use of personal protective equipment (ppe) for coronavirus disease (covid-19): interim guidance percentage of all active physicians by race/ethnicity fatal invention: how science, politics, and big business re-create race in the twenty-first century limits of epidemiology. medicine and global survival epidemiology and the people's health racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites structural racism and health inequities in the usa: evidence and interventions. the lancet white logic, white methods: racism and methodology how to be an antiracist safety and health topics | occupational noise exposure | occupational safety and health administration pulmonary function testing training requirements and spirometer transmission of disease. | occupational safety and health administration respiratory symptoms and lung function of aluminum potroom workers. scandinavian journal of work, environment & health compensation: benefits, coverage, and costs spirometric reference values from a sample of the general u.s. population. american journal of respiratory and critical care medicine race and sex differences in age-related hearing loss: the health, aging and body composition study association of skin color, race/ethnicity, and hearing loss among adults in the usa prevalence of hearing loss and differences by demographic characteristics among us adults: data from the national health and nutrition examination survey race difference in susceptibility to noise-induced hearing loss. the american journal of otology estimating the effect of occupational noise exposure on hearing thresholds: the importance of adjusting for confounding variables ama guides to the evaluation of permanent impairment guides to the evaluation of permanent impairment, 6th edition -division of federal employees' compensation (dfec) -office of workers' compensation programs (owcp) -u.s. department of labor software -niosh workplace safety and health topic national health and nutrition examination survey data: audiometry data lung function testing: selection of reference values and interpretative strategies comparison of smoking history patterns among african american and white cohorts in the united states born 1890 to 1990 covid-19 among workers in meat and poultry processing facilities -19 states territorial stigmatization in action smithfield foods is blaming "living circumstances in certain cultures" for one of america's largest covid-19 clusters building austin, building justice: immigrant construction workers, precarious labor regimes and social citizenship building a better texas: construction working conditions in the lone star state build a better nation: a case for comprehensive immigration reform stay home -work safe order information covid-19 in austin, texas: epidemiological assessment of construction work work session of the austin city council, item b001 -briefing on matters related to covid-19 coronavirus in austin: virus clusters showing up in construction, other industries austin health officials seeing spike in covid-19 cases among construction workers crowded housing and essential jobs: why so many latinos are getting coronavirus essential during the pandemic. workers worry their health is not mitigating the wider health effects of covid-19 pandemic response occupational prestige in the health care delivery system hospitals tell doctors they'll be fired if they speak out about lack of gear. fortune [electronic article these are the occupations with the highest covid-19 risk three new york city hospital workers died from coronavirus weeks after handing out masks. people.com [electronic article covid-19 nursing home data observational evidence of for-profit delivery and inferior nursing home care: when is there enough evidence for policy change? racial disparities in job strain among american and immigrant long-term care workers changes in nursing home staffing levels from servitude to service work: historical continuities in the racial division of paid reproductive labor bad state data hides coronavirus threat as trump pushes reopening the forgotten front line: nursing home workers say they face retaliation for reporting covid-19 risks state-reporting-of-cases-and-deaths-due-to-covid-19-in-long-term-carefacilities/) economic vulnerability among us female health care workers: potential impact of a $15-per-hour minimum wage covid-19 cases at one texas immigration detention center soared in a matter of days. now, town leaders want answers perspective | unions for prison, va workers file "imminent danger" reports about coronavirus conditions something is going to explode': when coronavirus strikes a prison. the new york times bop: covid-19 update nurse dies. angry co-workers blame a lack of protective gear. the new york times 3 hospital workers gave out masks. weeks later, they all were dead. the new york times florida governor defends firing of top data scientist revealing nursing homes with covid-19 outbreaks would hurt businesses. azcentral state won't name nursing homes where seniors are dying because it's .... bad publicity? azcentral chloroform, and the science of medicine: a life of john snow critical race theory, race equity, and public health: toward antiracism praxis key: cord-283673-oyefmgl3 authors: garcia, marc a; homan, patricia a; garcía, catherine; brown, tyson h title: the color of covid-19: structural racism and the pandemic’s disproportionate impact on older racial and ethnic minorities date: 2020-08-05 journal: j gerontol b psychol sci soc sci doi: 10.1093/geronb/gbaa114 sha: doc_id: 283673 cord_uid: oyefmgl3 objectives: the aim of this evidence-based theoretically informed essay is to provide an overview of how and why the covid-19 outbreak is particularly detrimental for the health of older black and latinx adults. methods: we draw upon current events, academic literature, and numerous data sources to illustrate how biopsychosocial factors place older adults at higher risk for covid-19 relative to younger adults, and how structural racism magnifies these risks for older black and latinx adults. results: we identify three proximate mechanisms through which structural racism operates as a fundamental cause of racial/ethnic inequalities in covid-19 burden among older adults: (1) risk of exposure; (2) weathering processes; and (3) health care access and quality. discussion: while the ongoing covid-19 pandemic is an unprecedented crisis, the racial/ethnic health inequalities among older adults it has exposed are long-standing and deeply rooted in structural racism within american society. this knowledge presents both challenges and opportunities for researchers and policymakers as they seek to address the needs of older adults. it is imperative that federal, state, and local governments collect and release comprehensive data on the number of confirmed covid-19 cases and deaths by race/ethnicity and age to better gauge the impact of outbreak across minority communities. we conclude with a discussion of incremental steps to be taken to lessen the disproportionate burden of covid-19 among older black and latinx adults, as well as the need for transformative actions that address structural racism in order to achieve population health equity. m a n u s c r i p t the united states (u.s.) is now the epicenter for the novel coronavirus disease pandemic, leading the world in the number of confirmed infections and deaths (dong, du, & gardner, 2020) . as of the end of july 2020, there have been over 4.3 million cases and 147,000 deaths as a result of covid-19 in the u.s. (hopkins, 2020) . since initial detection of the coronavirus in the state of washington on january 19, 2020, the number of reported cases has risen rapidly (holshue et al., 2020) . the spread of the coronavirus has varied geographically, with populous states such as new york, california, new jersey, illinois, texas, and florida hit particularly hard. as the pandemic began to unfold, local and state governments issued -shelter in place‖ and -social and physical distancing‖ mandates aimed at suppressing transmission of the coronavirus. following an overall flattening of the curve nationwide, most states began reopening their economies and easing social distancing restrictions during the summer months. despite some progress in reducing the number of covid-19 deaths, new hotspots continue to emerge, and the recent surge in outbreaks across the nation raises serious concerns for the upcoming fall and winter, particularly during influenza season. as the covid-19 outbreak rapidly evolves, identifying key factors that impact population health outcomes is crucial for formulating effective responses to the ongoing crisis. questions regarding which segments of u.s. society are at an elevated risk for severe illness and death from the coronavirus-and how and why-are central to understanding and addressing disparities in covid-19 health outcomes. evidence regarding which subpopulations are susceptible to the coronavirus reveals two key patterns: 1) covid-19 is particularly detrimental for the health of older adults, as evidenced by their disproportionately high rates of hospitalizations and mortality from the virus (bialek et al., 2020; garg et al., 2020) ; and 2) older black and latinx communities are particularly hard hit by the pandemic (cdc, 2020a; millett et m a n u s c r i p t rodriguez-diaz et al., 2020) . figure 1 illustrates covid-19 death rates per 100,000 population as of june 17, 2020 by age group for the total u.s. population and by race/ethnicity for adults aged 65 and older. results indicate that adults aged 65 and older are more than seven times as likely as younger adults to die from covid-19 (panel a). among older adults, blacks and latinxs have death rates approximately three and two times higher than whites, respectively (panel b). in order to understand racial/ethnic disparities in covid-19 health outcomes among older adults, it is important to consider how social and historical contexts contribute to different levels of risks over time. notably, current cohorts of older blacks and latinxs came of age during the jim crow era and consequently have endured overt and de jure racism as well as more contemporary subtle and de facto forms of racism (bonilla-silva, 1997) . contemporary structural racism involves -macrolevel systems, social forces, institutions, ideologies, and processes that interact with one another to generate and reinforce inequities among racial and ethnic groups‖ (gee & ford, 2011:116) . both theoretical and empirical research provide compelling evidence of contemporary structural racism in a myriad of societal domains, including (but not limited to) education, employment, housing, criminal justice, and health care systems (feagin & bennefield, 2014; gee & ford, 2011) . given their experiences --both past and present --living within a u.s. social system where myriad opportunities and risks are unequally distributed across the color line (bonilla-silva, 1997), it is not surprising that older blacks and latinxs experience an accumulation of health disadvantages vis-à-vis whites (boen, 2019) . indeed, research has identified racism as a fundamental or root cause of health inequalities (phelan & link, 2015; williams, lawrence, & a c c e p t e d m a n u s c r i p t davis, 2019). fundamental cause theory highlights how structural racism harms the health of racial/ethnic minorities through a number of replaceable intervening mechanisms, including constraining opportunities for avoiding risks and obtaining health-promoting resources, such as socioeconomic resources (e.g., education, occupation, income and wealth) and flexible resources (e.g., power, prestige, freedom, neighborhood context, and health care). these processes apply to an array of health conditions-including infectious diseases like covid-19 (laster pirtle, 2020; phelan & link, 2015) . below we discuss how proximate mechanisms place older blacks and latinxs at an elevated health risk from the covid-19 pandemic compared to whites, while also highlighting examples of why structural racism is a fundamental driver of these inequalities. we begin by briefly highlighting biopsychosocial factors that put older adults at higher risk than younger adults during the covid-19 crisis. next, we provide evidence on racial/ethnic inequalities in three proximate factors that contribute to adverse population health outcomes due to the covid-19 pandemic: (1) risk of exposure; (2) weathering processes; and (3) health care access and quality. importantly, by reviewing empirical evidence on how structural racism is a fundamental cause of racial/ethnic inequalities in risks, resources, and health (laster pirtle, 2020; phelan & link, 2015; williams et al., 2019) , we further elucidate why these inequalities are produced and maintained, and suggest how they can potentially be addressed. the covid-19 outbreak is particularly detrimental to older adults, impacting their wellbeing both directly and indirectly. in terms of direct effects of the pandemic, aging processes involve immunosenescence-age-related changes to the immune system which lead to increased morbidity and mortality rates due to infectious diseases (nikolich-žugich, 2018) . evidence a c c e p t e d m a n u s c r i p t indicates that older adults with underlying comorbidities are at an elevated risk of covid-19 infection due to comprised immune systems and are more likely to develop severe complications from exposure to the virus which results in a higher risk for mortality (bialek et al., 2020; garg et al., 2020) . in addition, older adults with underlying comorbidities may be at a higher risk of contracting and spreading the virus as they may require physical interactions with healthcare providers or reside in long-term care and assisted living facilities (cdc, 2020). the pandemic can also indirectly harm older adults. for example, to the extent that older adults forgo medical care and prescriptions due to fears of contracting covid-19, they are likely to experience increased health problems and mortality from otherwise manageable chronic conditions (girdhar, srivastava, & sethi, 2020) . moreover, physical distancing measures among older adults, particularly those who live alone, may result in social and psychological isolation and thereby increase negative mental health outcomes, including anxiety, depression, loneliness and difficulty coping with stressors in a time of crisis (girdhar et al., 2020) . although older adults are disproportionately impacted by the pandemic, not all older adults experience the pandemic with the same set of (dis)advantages. highlighting which older adults face systemic (dis)advantages is important to contextualize differing risks, resources, and health profiles (ferraro, kemp, & williams, 2017) . as covid-19 is an infectious disease, conditions in which people live and work are primary factors determining risk of exposure. structural racism in the forms of residential and occupational segregation (i.e. the unequal distribution of racial/ethnic groups across neighborhoods and jobs) and wealth inequalities shape living and working conditions in ways that put blacks and latinxs at greater risk of covid-19 exposure and limit their ability to a c c e p t e d m a n u s c r i p t practice physical distancing (ray, 2020) . residential segregation stems from both historical and contemporary forms of discriminatory government policies (e.g., exclusion from financial benefits of the new deal and gi bill) and institutional practices (e.g., unfair lending, redlining and blockbusting) (massey & denton, 1993; sewell, 2016) . compared to predominately white neighborhoods, majority black or latinx neighborhoods are more likely to be harmful ecological environments, characterized by densely populated areas, concentrated economic disadvantage, high crime rates, few healthy food options and green spaces, and subpar housing (massey & denton, 1993; sewell, 2016) . research has shown that neighborhood conditions are particularly salient for the health and well-being of older adults (cagney, browning, & wen, 2005) . due to constrained mobility, older blacks and latinxs adults are more likely to be exposed to unhealthy environments which contribute to adverse health outcomes over time. racial/ethnic segregation of nursing homes also puts older blacks and latinxs at greater risk than whites of exposure to covid-19. although fewer blacks and latinxs than whites reside in long-term care facilities, minorities are concentrated in predominantly non-white facilities with lower quality and cleanliness (howard et al., 2002) . as of may 16, 2020, 60% of nursing homes where at least a quarter of residents are black or latinx had at least 1 covid-19 case, while only 30% of homes with almost entirely white (<5% black or latinx) residents had a case (gebeloff et al. 2020). finally, blacks and latinxs are also overrepresented among the jail/prison population, subjecting them to crowded and unhygienic living quarters (cdc, 2020c). these living conditions make it more difficult to practice preventive measures and go about routine daily activities without risk of covid-19 exposure. large racial/ethnic wealth gaps and occupational segregation are also likely to contribute to elevated covid-19 risks for older blacks and latinxs. whereas older white households have a c c e p t e d m a n u s c r i p t an average net worth of $258k, the averages for older black and latinx households are only $13k and $39k, respectively (brown, 2016) . thus, it is not surprising that older blacks and latinxs are more likely to live in crowded, multi-generational households than whites (vespa, lewis, & kreider, 2013) , which likely increases their risk of exposure to covid-19 due to limited space to isolate from household members who have been exposed or infected. moreover, many older blacks and latinxs must continue working outside the home despite outbreaks in their communities due to economic necessity, increasing their risk of exposure. black and latinx adults are overrepresented in high-contact occupations in food, retail, service, transportation, and health industries that have been categorized as -essential.‖ for example, blacks and latinxs both represent approximately 25% of service industry workers, and 16% of production and transportations workers compared to 16% and 11% for whites, respectively (u.s. bureau of labor statistics, 2019). these occupations are less likely to have paid sick leave which can increase exposure to covid-19 for workers and their families every time they go to work, particularly those who rely on public (i.e. crowded) transportation (ray, 2020) . blacks and latinxs are also less likely to work remotely than whites (18% and 13% compared to 26%, respectively) (u.s. bureau of labor statistics, 2019). thus, -shelter in place‖ mandates to reduce transmission of covid-19 may be less protective for older blacks and latinxs than whites as they are less likely to have access to healthy housing, paid sick leave, and often lack flexible work arrangements that allow them to work from home (gould & shierholz, 2020) . not only are older blacks and latinxs at higher risk of exposure to covid-19, they are also more likely than whites to experience serious complications or death as a result of the virus, due in part to underlying health conditions (garg et al., 2020) . from a fundamental cause a c c e p t e d m a n u s c r i p t perspective, we argue that structural racism is a pre-existing pathological social condition that drives weathering processes resulting in the greater chronic disease burden among blacks and latinxs that elevates their risk of health complications and death from covid-19. as noted above, theory and empirical data show that numerous manifestations of structural racism across social, economic, political and judicial systems are interrelated and lead to racial/ethnic health inequalities via an array of replaceable mechanisms, including unequal access to socioeconomic and flexible resources as well as exposure to risk factors such as environmental toxins, discrimination and other social stressors (gee & ford, 2011; sewell, 2016) . these structurallyrooted inequalities accumulate across domains, generations, and the life course, leading to weathering processes characterized by black and latinx adults experiencing greater physiological dysregulation, inflammation, and accelerated biological aging, vis-à-vis whites (crimmins & seeman, 2004; geronimus, hicken, keene, & bound, 2006; goosby, cheadle, & mitchell, 2018) . for example, research shows that racism-related adversity and stressors result in increased activity in the sympathetic nervous system (e.g., increases in blood pressure) and the hypothalamic-pituitary-adrenal axis (e.g., elevated circulating hormone levels); when these physiological stress responses are repeatedly activated they lead to increased risks for an array of health conditions (geronimus et al., 2006; goosby et al., 2018; miller, chen, & parker, 2011) . thus, it is not surprising that older black and latinx adults (1) have more underlying health conditions than whites (e.g. cardiovascular disease, diabetes, hypertension, chronic lung disease, and obesity); (2) experience health deterioration earlier in life; and (3) experience steeper health declines with age that results in a higher burden of disease (brown, 2018; garcia, garcia, & ailshire, 2018; garcia, garcia, chiu, raji, & markides, 2018) . these weathering processes are key mechanisms thorough which cumulative exposure to racism over the life a c c e p t e d m a n u s c r i p t course -gets under the skin,‖ undermining the health of older black and latinx adults and, in turn, leading to their disproportionately high rates of mortality from covid-19 related to preexisting health conditions. unequal health care access and quality place older racial/ethnic minorities at heightened risk of health problems arising from the covid-19 outbreak (laster pirtle, 2020). given their overrepresentation in low-wage jobs that lack health benefits, older racial/ethnic minorities are less likely than whites to have employer-provided health insurance, creating significant barriers to accessing and affording medical care (brown, 2018) . when blacks and latinxs navigate past these barriers and access the health care system, they often receive lower quality of care than whites due to both structural inequalities and physician bias (smedley, stith, & nelson, 2003) . in addition, residential segregation shapes the distribution of patients across hospitals such that the worst hospitals (in terms of quality and cost) care for double the proportion of older black patients as the best hospitals (jha, orav, & epstein, 2011) . studies also show that minorities have longer waiting times before seeing a provider, and are less likely to have their pain appropriately diagnosed and effectively treated due to structural constraints, racialized stereotypes, and false beliefs regarding genetic differences on the part of health care providers (hoffman, trawalter, axt, & oliver, 2016) . such delays and ineffectiveness in diagnosis and treatment can prove deadly for minority covid-19 patients who may be in a fragile state of health. finally, ethical guidelines for the allocation of scarce medical resources during the pandemic will likely exacerbate existing racial inequalities in quality of care. recommendations published in the new england journal of medicine suggest -giving priority to younger patients and those with fewer a c c e p t e d m a n u s c r i p t coexisting conditions‖ (emanuel et al., 2020) . this practice would disproportionately harm older racial/ethnic minorities given their higher rates and earlier onset of chronic conditions. while the ongoing covid-19 pandemic is an unprecedented crisis, the racial/ethnic health inequalities it has exposed are long-standing and deeply rooted in american society. increased risk of exposure to the virus, weathering processes, and reduced health care quality and access are key proximate mechanisms that explain how the covid-19 outbreak is disproportionately harming older black and latinx adults. however, understanding why these disparities are produced and maintained requires a recognition that structural racism-in its myriad manifestations-is a fundamental cause of health disparities. this knowledge presents both challenges and opportunities for researchers and policymakers as they seek to address the needs of older adults. several immediate steps can be taken to lessen the burden of covid-19 in black and latinx communities. first, state and local public health agencies must place testing and triage centers in minority neighborhoods to help reduce the racial/ethnic gap in covid-19 cases and deaths. second, governments need to provide economic relief directly to individuals (and households), which is particularly important for the financial security of older black and latinx adults given that they have less wealth than older whites to cushion the economic shock of the pandemic (brown, 2016) . third, workers deemed -essential‖ should be provided personal protective equipment, paid leave, hazard pay and health care. fourth, health care organizations must ensure that racial bias and seemingly -race-neutral‖ policies and practices do not have a disparate impact on older racial/ethnic minorities (ray, 2019) . fifth, in order to understand how a c c e p t e d m a n u s c r i p t the pandemic impacts vulnerable subpopulation groups, it is imperative that federal, state, and local governments collect and release comprehensive data on the number of confirmed covid-19 cases and deaths by race/ethnicity and age across a range of sociodemographic characteristics (e.g., nativity, country of origin, age of migration, and gender) which are known to individually and collectively shape health and mortality outcomes (arias, johnson, & vera, 2020; brown, 2018; m. a. garcia et al., 2018; reyes & garcia, 2019) . a key insight from fundamental cause theory is that, due to shifting and replaceable intervening mechanisms, minority communities will continue to bear a disproportionate burden of suffering and excess death before, during, and after public health crises-unless structural racism is adequately addressed (laster pirtle, 2020) . in order to address structural racism, scholars have proposed a number of bold actions such as criminal justice reform, a federal jobs guarantee, reparations, universal health care, and desegregation of schools, jobs and neighborhoods. this is consistent with the growing recognition that dismantling structural racism through transformative actions across societal domains is essential for achieving population health equity. a c c e p t e d m a n u s c r i p t m a n u s c r i p t figure 1 racial disparities in mortality in the adult hispanic population. ssm-population health severe outcomes among patients with coronavirus disease 2019 (covid-19)-united states death by a thousand cuts: stress exposure and black-white disparities in physiological functioning in late life rethinking racism: toward a structural interpretation diverging fortunes: racial/ethnic inequality in wealth trajectories in middle and late life racial stratification, immigration, and health inequality: a life course-intersectional approach racial disparities in selfrated health at older ages: what difference does the neighborhood make? preventing the spread of covid-19 in retirement communities and independent living facilities (interim guidance) weekly updates by select demographic and geographic characteristics: provisional death counts for coronavirus (covid-19) covid-19 in racial and ethnic minority groups integrating biology into the study of health disparities. population and development review an interactive web-based dashboard to track covid-19 in real time. the lancet infectious diseases fair allocation of scarce medical resources in the time of covid-19 systemic racism and us health care. social science & medicine diverse aging and health inequality by race and ethnicity sociocultural variability in the latino population: age patterns and differences in morbidity among older us adults a comprehensive analysis of morbidity life expectancies among older hispanic subgroups in the united states: variation by nativity and country of origin hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed coronavirus disease 2019-covid-net, 14 states structural racism and health inequities: old issues, new directions weathering‖ and age patterns of allostatic load scores among blacks and whites in the united states managing mental health issues among elderly during covid-19 pandemic stress-related biosocial mechanisms of discrimination and african american health inequities not everybody can work from home black and hispanic workers are much less likely to be able to telework racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites first case of 2019 novel coronavirus in the united states coronavirus resource center. im internet distribution of african americans in residential care/assisted living and nursing homes: more evidence of racial disparity? low-quality, high-cost hospitals, mainly in south, care for sharply higher shares of elderly black, hispanic, and medicaid patients racial capitalism: a fundamental cause of novel coronavirus (covid-19) pandemic inequities in the united states. health education & behavior american apartheid: segregation and the making of the underclass psychological stress in childhood and susceptibility to the chronic diseases of aging: moving toward a model of behavioral and biological mechanisms assessing differential impacts of covid-19 on black communities the twilight of immunity: emerging concepts in aging of the immune system is racism a fundamental cause of inequalities in health? why are blacks dying at higher rates from covid-19 a theory of racialized organizations gender and age of migration differences in mortality among older mexican americans risk for covid-19 infection and death among latinos in the united states: examining heterogeneity in transmission dynamics institute of medicine, committee on understanding and eliminating racial and ethnic disparities in health care. unequal treatment: confronting racial and ethnic disparities in healthcare labor force characteristics by race and ethnicity america's families and living arrangements: 2012 racism and health: evidence and needed research key: cord-102783-f8i20twx authors: jbaily, a.; zhou, x.; liu, j.; lee, t.-h.; verguet, s.; dominici, f. title: inequalities in air pollution exposure are increasing in the united states date: 2020-07-15 journal: nan doi: 10.1101/2020.07.13.20152942 sha: doc_id: 102783 cord_uid: f8i20twx exposure to ambient air pollution contributes substantially to the global burden of disease, and in 2015, ambient exposure to pm2.5 (fine particles with a mass median aerodynamic diameter of less than 2.5 m) was the fifth-ranking risk factor of mortality globally. we analyzed data from the us zip code tabulation areas (n=32047) for 2000-2016 and found strong evidence of inequalities in exposure to pm2.5 among both racial/ethnic and income groups. most alarming, we found that these inequalities have been increasing over time. from 2010 to 2016 inequalities in the exposure to pm2.5 levels above 8 g/m3 across racial/ethnic, and income groups increased by factors of 1.6 and 4.0 respectively. as shown in our powerful map visualizations, these results indicate that air pollution regulations must not only decrease pm2.5 concentration levels nationwide but also prioritize reducing environmental injustice across the us. strong associations exist between exposure to pm 2.5 (fine particles with a mass median aerodynamic diameter of less than 2.5 µm) in the us and adverse health outcomes such as hospital admissions [1, 2, 3, 4] and mortality [5, 6, 7, 8, 9, 10] . it is well documented that minorities and people of low socioeconomic status in the us are at a higher risk of death from being exposed to pm 2.5 [11, 12, 13, 14] . although inequalities in air pollution exposure among racial/ethnic and socioeconomic groups in the us are known to exist [15, 16, 17, 18] , it is unknown whether these inequalities are being addressed. here we provide strong and concerning evidence that although air pollution in the us has decreased over the years, disparities among racial/ethnic populations and socioeconomic groups have increased. we found that black populations and lower income groups are exposed to the highest levels of particulate matter across the study period and that inequalities in exposure to particulate matter among racial/ethnic communities have doubled between 2010 and 2016. our findings have strong and time-sensitive implications on policies set by the us environmental protection agency (epa) to combat racial injustice and the higher death toll of covid-19 among minorities. the us epa is required to reexamine its national ambient air quality standards (naaqs) every five years. in 2012 the epa set the naaqs for pm 2.5 to 12 µg/m 3 [19] . on average across the us, we found that pm 2.5 has decreased by 43% (animation 1 in supplementary material; and extended data figure a.1). we also found that the percentage of the population exposed to pm 2.5 levels higher than 12 µg/m 3 decreased from 62.8% in 2000 to 0.23% in 2016 (map shown in extended data figure a.2). for each racial/ethnic group (white, black, asian, and hispanic) 1 , we construct a map that shows only zip code tabulation areas (zctas) where the race/ethnicity is most present 2 to quantify these differences in exposure, we compute the population-weighted average pm 2.5 concentration for every racial/ethnic population (please see methods) (extended data figure a.4a). for all years, we found that the black population is exposed to higher levels of pm 2.5 compared to other racial/ethnic groups. to visualize this finding for 2016, we illustrate how the population-weighted pm 2.5 average concentration changes as zctas become more populated by a certain race/ethnicity (extended data figure a.4b). we found that as the black population increases in a zcta, the pm 2.5 concentration consistently increases and a very steep incline is seen for zctas with more than 85% of their population as black. the trend of the hispanic population follows that of the black population except at population fractions above 85%. the opposite is seen for white populations; pm 2.5 concentration decreases as density of the white population increases in zctas; a steep decrease is shown for zctas with a white population 2 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted july 15, 2020. . fraction exceeding 70%. further, in zctas where the population of native americans is at least 80%, the average pm 2.5 concentration drops to below 4 µg/m 3 . when the asian population size increases there is no notable change in the average pm 2.5 concentration. disparities in air pollution exposure among income groups disparities exist among distinct income groups, with low-income groups exposed to the highest pm 2.5 concentrations. we assign all zctas percentile ranks from 1 to 100 based on median household income and categorize them into ten income groups. we designate the lowest and highest three income groups as low-income and high-income respectively and then split the us map into two maps -zctas defined as low-and high-income (please see methods). we visualize the pm 2.5 concentration distribution on the two maps for 2000 to 2016 (animation 3 in supplementary material). the low-income map appears to be dominated by an overall higher concentration of pm 2.5 as compared to the high-income map especially in recent years. we include snapshots of 2000 and 2016 (figure 2). in 2016 for example, ∼ 80% of zctas of the high-income us map had pm 2.5 concentrations lower than 8 µg/m 3 compared to only ∼ 70% of the zctas of the low-income map (figure 2b). we summarize the contents of the maps by computing the average pm 2.5 concentration for the low-and high-income groups (extended data figure a.5); the pm 2.5 concentration is consistently higher for the low-income group, except in 2001. further, we isolate the effects of income on the disparities among the racial/ethnic groups in extended data figures a.6a and a.6b. we found that although air pollution in the us has decreased, inequality in breathing polluted air has increased among the different racial/ethnic and income groups. to visualize this finding, for each year and for each race, we ranked the us zctas from the least dense to the most dense with respect to that race 3 (extended data figure a.7a). for example, in figure 3a the dark blue region on the black population map contains the zctas with the highest ratio of black population to total zcta population, and the light yellow region contains the zctas with the lowest ratio of black population to total zcta population. similarly, the white population map in figure 3a contains dark blue and light yellow regions that correspond to high and low white population proportions respectively. in figure 3a, we only show for the black and white populations the zctas with a pm 2.5 concentration higher than 8 µg/m 3 for the year 2010 (i.e. high pollution zctas). this figure reveals that almost half of these high pollution zctas are where the black population is concentrated (southern part of the map as indicated by the dark blue region on the black population us map), and the other half is where the white population is concentrated (northern part of the map as indicated by the dark blue region on the white population us map). however, reexamining the high pollution zctas for 2016 (figure 3b) shows that only those with concentrated black populations remain above the pm 2.5 threshold (majority of the black population map is dark blue and that of the white population map is light yellow). in summary, air pollution reduction regulations between 2010 and 2016 were enforced and attained in the areas dominated by the white populations whereas the black populations are still living with high pm 2.5 levels; this clearly indicates an increase in disparities to air pollution exposure among the white and black populations as will be numerically shown later. additionally, we extend figure 3 to include the hispanic and asian populations and present the results in extended data figures a.7b and a.7c. we also repeat the same visualization for thresholds different than 8 µg/m 3 and present them in animation 4 in supplementary material, which shows the distribution of the different racial/ethnic communities across multiple pm 2.5 concentrations for 2010 and 2016. furthermore, we quantify such variation in disparities to air pollution exposure among racial/ethnic (and income) groups using the coefficient of variation cov (please see methods) and summarize our findings in figure 4 . for example, interpreting the figures for 2010 and 2016 (shown in figures 3a and 3b), we find that 75% of the population was exposed to pm 2.5 levels higher than 8 µg/m 3 in 2010, whereas only 36% in 2016 (solid blue line). however, the cov shows that the variation in air pollution exposure among racial/ethnic groups relative to its mean increased from 0.17 3 ranking the zctas for a particular race is done by using the population fraction of the race in every zcta to split them into 100 quantiles by using percentiles. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 15, 2020. . https://doi.org/10.1101/2020.07.13.20152942 doi: medrxiv preprint in 2010 to 0.27 in 2016, which shows that exposure disparities among racial/ethnic groups have increased by a factor of 1.58. this is in agreement with figure 3. it is interesting to note that inequality in exposure to pm 2.5 levels above 8 µg/m 3 remained constant between 2010 and 2014, and started to increase in 2015. figure 4a shows the analysis for a threshold t = 10 µg/m 3 , which reveals greater inequalities. the analysis is also applied for the case of the ten income groups instead of the racial/ethnic groups (figure 4b). we observe that inequality in exposure to pm 2.5 levels above 10 µg/m 3 across income groups decreased from 2010 to 2013 and then started to increase. further, the level of inequality among income groups as measured by cov is smaller than that observed among racial/ethnic groups. in addition to using the easily interpretable cov, we repeated the inequality analysis of figure 4 using the atkinson index, an alternative inequality metric used in the literature [16, 20, 21] . these findings are located in extended data figure a.8 and are similar to those of figure 4 which confirms the increase in disparities in exposure to air pollution among racial/ethnic groups and among income groups. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 15, 2020. . https://doi.org/10.1101/2020.07.13.20152942 doi: medrxiv preprint . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 15, 2020. . https://doi.org/10.1101/2020.07.13.20152942 doi: medrxiv preprint we built a dataset that includes all us zctas 4 for 2000 to 2016 and contains demographic (median household income, racial/ethnic distribution, etc.) and pollution data (pm 2.5 concentrations) and investigated temporal patterns in pm 2.5 levels and in air pollution exposure of racial/ethnic and income groups. pm 2.5 concentrations decreased drastically from 2000 to 2016, where the population-weighted average of pm 2.5 has decreased by 43% from the year 2000 (13 µg/m 3 ) to 2016 (7.3 µg/m 3 ). further, it was evident that air pollution exposure disparities exist among both racial/ethnic and income groups. when investigating the air pollution exposure of the different racial/ethnic communities, we found that the black population is consistently exposed to higher levels of pm 2.5 on average. in 2016, the average pm 2.5 concentration for the black population was 11.6% higher than that of the white population and 28.6% higher than that of the native american population. the native american population was consistently exposed to the lowest levels of air pollution from 2000 to 2016 (extended data figure a.4a) . additionally, we found that as the black population in zctas increased, the average pm 2.5 concentration increased; a steep increase was observed in zctas where the black population exceeded 85% of the population (extended data figure a.4b) . contrary to trends of the black populations, the average pm 2.5 concentration decreased as zctas became more populated with the white and native american populations (extended data figure a.4b) . the analysis also showed that the low-income group consistently suffers from worse air conditions compared to higher-income groups. in 2016, the average low-income population pm 2.5 concentration was 6.9% higher than that of the high-income population (extended data figure a.5). of note, exposure disparities in racial/ethnic and income groups are related to geographical distribution. for example, the industrial nature of southern us may result in less strict pollution regulations and is more polluted. at the same time, southern states have higher black and low income populations. the most pertinent and concerning finding of our study is that even though air pollution has decreased, exposure disparities among both racial/ethnic groups and income groups (as measured by the coefficient of variation and atkinson index) have increased. indeed, figure 3 shows that air pollution reduction strategies from 2010 and 2016 mainly resulted in air pollution reduction in areas where the white population is most concentrated. the results of increasing inequalities in air pollution exposure are timely and concerning at a time where the us is facing crises of racism, and health disparities in covid-19 health outcomes. there is an emerging research area in the us and around the world that provides preliminary evidence that long-term air pollution exposure increases susceptibility to covid-19 [22] . furthermore, it has been documented that racial minorities have higher covid-19 death rates [23, 24] . the results of this paper show that the epa must not only act to decrease nationwide pm 2.5 concentration levels on average but must also devise air pollution reduction strategies to reduce pollution exposure of minority and low-income populations to address environmental injustice. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 15, 2020. . https://doi.org/10.1101/2020.07.13.20152942 doi: medrxiv preprint supplementary material is available upon request from corresponding author. data will be made accessible through the publishing journal upon manuscript acceptance. the code will be made accessible through the publishing journal upon manuscript acceptance. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 15, 2020. . https://doi.org/10.1101/2020.07. 13.20152942 doi: medrxiv preprint the authors declare no competing interests. our dataset includes all us zip code tabulation areas 5 (zctas) for 2000 to 2016 (n=32047). for each zcta, we obtained demographic and socioeconomic variables from the us census bureau when available and used interpolation techniques (moving average) to determine those of the missing years. variables of interest comprised median household income, proportions of native americans, asian, white, black, and hispanic residents, and population density. for each year, we assigned all zctas percentile ranks from 1 to 100 based on median household income and categorized them into ten income groups. throughout the paper we use low-income and high-income to label the lowest three and highest three income groups respectively. we also used previously in-house developed prediction models to estimate pm 2.5 concentration levels on 1 km by 1 km nationwide grids [25, 26] . these use a validated ensemble-based model, which integrates three machine learning (ml) algorithms including gradient boosting, neural network, and random forest. these ml algorithms used more than 100 predictor variables from satellite data, land-use terms, meteorological variables, and chemical transport model predictions. the ensemble-based model was calibrated using daily pm 2.5 concentrations measured at 2,156 us epa monitoring sites, with an average cross-validated r 2 of 0.86 and an unbiased slope, indicating excellent model performance. for each zcta we calculated the daily average pm 2.5 based on all covered 1 km 2 grid cells and then computed annual averages. the annual averages of pm 2.5 levels for each zcta were included in the dataset. we built one dataset by combining the demographic and pm 2.5 variables across all us zctas for 2000 to 2016. our dataset analysis reveals time patterns in air pollution across the us and inequalities in exposure to air pollution among racial/ethnic and income groups. dynamic animations are used to communicate our findings along with plots that summarize and clarify the information embedded in our visualizations. we first defined a group population-weighted pm 2.5 concentration, where a group can be an income group such as the first decile, or an ethnic group such as the hispanic population. in the case of racial/ethnic groups, the populationweighted pm 2.5 concentration in racial/ethnic group k is given by: 5 demographic data for multiple zctas (2.7%) were missing. as a result, these geographic areas were not included in the analysis or animations. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 15, 2020. . where summation occurs over all zctas. p k, j is the number of people in racial group k living in the zcta j, and pm 2.5 j is the pm 2.5 level in the zcta j. in the case of income groups, the population-weighted pm 2.5 concentration of income group i is: where summation occurs only over zctas j belonging to the income group i. p j is the total population of zcta j, and pm 2.5 j is the pm 2.5 level in zcta j. additionally, we defined a second pm 2.5 -related variable (q) and use it to quantify the level of inequality in exposure to pm 2.5 concentrations among the different racial/ethnic or income groups. the variable q is defined as the percentage of a population exposed to pm 2.5 levels above a certain pm 2.5 threshold t . we can calculate q for specific population subgroups. for example, we can compute the percentage of the population in the highest income group that is exposed at pm 2.5 levels above t = 12 µg/m 3 , or the percentage of a racial/ethnic group, such as native americans, exposed to pm 2.5 levels above t = 8 µg/m 3 . to measure the degree of inequality across racial/ethnic (or income) groups in exposure to pm 2.5 concentrations above t for a specific year, we first compute q for every racial/ethnic (or income) group. we then compute the coefficient of variation (cov) defined as: where var is the variance of q and µ is the mean of q. cov measures the variability of a series of numbers independent of the data magnitude, so it captures the variation in q among racial/ethnic (or income) groups in a given year relative to the mean pollution levels during that year. for example, consider three years y 1 , y 2 and y 3 , where the percentages of five racial/ethnic groups being exposed to pm 2.5 levels above a threshold t are, respectively: q 1 = (11%, 13%, 14%, 15%, 17%) q 2 = (10%, 12%, 14%, 16%, 18%) q 3 = (1%, 1.2%, 1.4%, 1.6%, 1.8%) from y 1 to y 2 , the coefficient of variation increases from cov 1 = 0.143 to cov 2 = 0.202, which indicates that the variation in exposure to air pollution relative to the mean, and equivalently disparities among the racial/ethnic groups, increased by a factor of 1.4. on the other hand, although the pollution levels decreased drastically between y 2 and y 3 as can be seen by the different orders of magnitude of q 2 and q 3 , the coefficient of variation is unchanged (cov 3 = 0.202) indicating that the inequalities in exposure to air pollution among the racial/ethnic groups is the same between y 2 and y 3 . these examples highlight the power of using cov to capture relative variation in the data independently of its magnitude. this is very important for our application because the level of pollution changes considerably over the years. the outlined procedure of quantifying inequality through cov can be applied for any pm 2.5 threshold t and can be repeated for all years to track the evolution of inequality in exposure to air pollution among the different racial/ethnic (or income) groups. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 15, 2020. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 15, 2020. . https://doi.org/10.1101/2020.07.13.20152942 doi: medrxiv preprint . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 15, 2020. . https://doi.org/10.1101/2020.07.13.20152942 doi: medrxiv preprint cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 15, 2020. . https://doi.org/10.1101/2020.07.13.20152942 doi: medrxiv preprint the population-weighted pm 2.5 average concentration across racial/ethnic communities as a function of zcta racial/ethnic population (%) for 2016. when the racial/ethnic population % is equal to 0.2, the red curve includes every zcta where the black population is 20% or more, and the blue curve includes every zcta where the white population is 20% or more. as zcta's black and hispanic populations increase, the pm 2.5 concentration levels increase. the opposite effect is seen for the white and native american communities. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 15, 2020. . https://doi.org/10.1101/2020.07.13.20152942 doi: medrxiv preprint 14 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 15, 2020. . https://doi.org/10.1101/2020.07.13.20152942 doi: medrxiv preprint it is interesting to note that for the native american population, low-income groups are exposed to lower concentrations of pm 2.5 as compared to the high-income groups. this may be tied to the rurality vs. urbanicity of the zctas, which was not included in our analysis. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted july 15, 2020. . https://doi.org/10.1101/2020.07.13.20152942 doi: medrxiv preprint . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted july 15, 2020. . https://doi.org/10.1101/2020.07.13.20152942 doi: medrxiv preprint figure 4 , disparities in air pollution exposure among racial/ethnic groups and income groups are increasing. further, disparities among racial/ethnic groups are higher than those among income groups, and disparities above a pm 2.5 threshold of 10 µg/m 3 are higher than above 8 µg/m 3 . the atkinson index was computed using the inequality package "ineq" in the r software. the input is the proportion of the racial/ethnic (or income) groups living above the set pm 2.5 threshold. we set the atkinson aversion parameter = 0.75 [16] . . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted july 15, 2020. . https://doi.org/10.1101/2020.07.13.20152942 doi: medrxiv preprint fine particulate air pollution and hospital admission for cardiovascular and respiratory diseases seasonal and regional short-term effects of fine particles on hospital admissions in 202 us counties short term effects of particle exposure on hospital admissions in the mid-atlantic states: a population estimate airborne fine particles and risk of hospital admissions for understudied populations: effects by urbanicity and short-term cumulative exposures in 708 us counties national maps of the effects of particulate matter on mortality: exploring geographical variation effects of long-term exposure to air pollution on natural-cause mortality: an analysis of 22 european cohorts within the multicentre escape project ambient pm2. 5, o3, and no2 exposures and associations with mortality over 16 years of follow-up in the canadian census health and environment cohort (canchec) estimating the causal effect of fine particulate matter levels on death and hospitalization: are levels below the safety standards harmful? association of short-term exposure to air pollution with mortality in older adults evaluating the impact of long-term exposure to fine particulate matter on mortality among the elderly air pollution and mortality in the medicare population evidence on vulnerability and susceptibility to health risks associated with short-term exposure to particulate matter: a systematic review and meta-analysis long-term exposure to pm2. 5 and mortality among older adults in the southeastern us pm2. 5 and mortality in 207 us cities: modification by temperature and city characteristics environmental inequality in exposures to airborne particulate matter components in the united states temporal trends in air pollution exposure inequality in massachusetts disparities in distribution of particulate matter emission sources by race and poverty status making the environmental justice grade: the relative burden of air pollution exposure in the united states process of reviewing the national ambient air quality standards national patterns in environmental injustice and inequality: outdoor no2 air pollution in the united states incorporating concepts of inequality and inequity into health benefits analysis exposure to air pollution and covid-19 mortality in the united states racial data transparency -state covid-19 data by race, john's hopkins university and medicine -coronavirus resource center the washington post assessing pm2. 5 exposures with high spatiotemporal resolution across the continental united states an ensemble-based model of pm2. 5 concentration across the contiguous united states with high spatiotemporal resolution the authors would like to thank joel d. schwartz for providing the air pollution data, benjamin sabbath for cleaning and preparing the datasets, and lauren bennett for comments and discussions. this work was supported financially by grants from the health effects institute (4953-rfa14-3/16-4), national institute of health (dp2md012722), national institute of health and yale university (r01md012769), national institute of health and national institute of environmental health sciences (r01 es028033) and the environmental protection agency (83587201-0). aj, sv and fd contributed to the study design. aj led the research with supervision from fd. xz, jl and thl prepared the map animations. aj drafted the manuscript with support from xz, jl, thl, sv and fd. all authors read and approved the final manuscript for submission. key: cord-314538-l4ek54cu authors: lin, peng; ye, xiujuan; ng, tb title: purification of melibiose‐binding lectins from two cultivars of chinese black soybeans date: 2008-12-16 journal: acta biochim biophys sin (shanghai) doi: 10.1111/j.1745-7270.2008.00488.x sha: doc_id: 314538 cord_uid: l4ek54cu a dimeric 50 kda melibiose‐binding lectin was isolated from the seeds of the cultivar of soybean (glycine max), called the small glossy black soybean. the isolation procedure comprised ion exchange chromatography on q sepharose, sp sepharose and mono q followed by gel filtration on superdex 75. the lectin was adsorbed on all three ion exchangers, and it exhibited an n‐terminal sequence identical to that of soybean lectin. of all the sugars tested, melibiose most potently inhibited the hemagglutinating activity of the lectin, which was stable between ph 3‐12 and 0‐70 °c. the lectin evoked maximal mitogenic response at about the same molar concentration as con a. however, the response was much weaker. the soybean lectin inhibited the activity of hiv‐1 reverse transcriptase as well as the proliferation of breast cancer mcf7 cells and hepatoma hepg2 cells with an ic(50) of 2.82 μm, 2.6 μm and 4.1 μm, respectively. there was no antifungal activity. another lectin was isolated from a different cultivar of soybean called little black soybean. the lectin was essentially similar to small glossy black soybean lectin except for a larger subunit molecular mass (31 kda), a more potent mitogenic activity and lower thermostability. the results indicate that different cultivars of soybean produce lectins that are not identical in every aspect. a dimeric 50 kda melibiose-binding lectin was isolated from the seeds of the cultivar of soybean (glycine max), called the small glossy black soybean. the isolation procedure comprised ion exchange chromatography on q sepharose, sp sepharose and mono q followed by gel filtration on superdex 75. the lectin was adsorbed on all three ion exchangers, and it exhibited an n-terminal sequence identical to that of soybean lectin. of all the sugars tested, melibiose most potently inhibited the hemagglutinating activity of the lectin, which was stable between ph 3−12 and 0−70 ºc. the lectin evoked maximal mitogenic response at about the same molar concentration as con a. however, the response was much weaker. the soybean lectin inhibited the activity of hiv-1 reverse transcriptase as well as the proliferation of breast cancer mcf7 cells and hepatoma hepg2 cells with an ic 50 of 2.82 µm, 2.6 µm and 4.1 µm, respectively. there was no antifungal activity. another lectin was isolated from a different cultivar of soybean called little black soybean. the lectin was essentially similar to small glossy black soybean lectin except for a larger subunit molecular mass (31 kda), a more potent mitogenic activity and lower thermostability. the results indicate that different cultivars of soybean produce lectins that are not identical in every aspect. keywords purification; melibiose-binding lectin; chinese black soybean lectins are proteins that exhibit carbohydrate-binding specificity. they can be divided into groups, such as mannose-binding, glucose/mannose-binding, nacetylglucosamine-binding, galactose-binding, nacetylgalactosamine-binding, fucose-binding, and sialic acid-binding, according to their carbohydrate-binding specificity. lectins have been isolated from a diversity of organisms including flowering plants [1] , animals [2, 3] , fungi [4] , and bacteria [5] . many biological activities, including anti-proliferative, anti-tumor, immunopotentiating, anti-insect, antifungal, antiviral and antibacterial activities, have been found in lectins [6−11] . as a result, lectins have captured the attention of many investigators. soybean is an agricultural crop of great importance. from it, many important proteins and non-proteinaceous compounds have been isolated. they comprise trypsin inhibitors [12] , lectins [13] , antifungal proteins [14] , and phytoestrogens [15] . phytoestrogens are reported to be protective against osteoporosis and cardiovascular disease [15, 16] . soybean trypsin inhibitor has an anti-tumor action [17] . soybeans have been made into a variety of food products including drinks and bean curds. as stated in ben cao gang mu by li shizhen published in 1590, the black soybean is used in traditional chinese medicine for treating backaches, combating debility and preventing aging. according to current popular literature, the black soybean has more protein, potassium and vitamins than the yellow soybean [18] . the former has chlorophyll and black pigment while the latter has carotenoids. different cultivars of the same species may produce different proteins; for example, the miraculin-like antifungal protein sativin and the ribosome-inactivating protein pisavin, which has similar sequence to miraculin, are produced by different cultivars of pisum sativum, the sugar snap and the garden pea, respectively [19, 20] . different cultivars of soybean exist, including the yellow soybean, chinese black soybean and japanese black soybean. the yellow soybean produces trypsin inhibitors of the bowman-birk type and also the kunitz type [12] . the chinese dull black soybean produces only the kunitztype trypsin inhibitor [21] , whereas the japanese black soybean produces only the bowman-birk type [22] . thus different cultivars may have dissimilar protein products. lectin from yellow soybeans has been isolated and characterized. however, it is not known if the chinese black soybean produces the same lectin. the chinese black soybean is a special cultivar of soybean that differs from the common yellow soybean in pharmacological activities in traditional chinese medicine. thus, it was deemed worthwhile to isolate a lectin from each of the two cultivars of chinese black soybean, namely the chinese small glossy black soybean and the chinese little black soybean, to compare them with the lectin from common yellow soybean, and to explore other potentially exploitable activities of the lectins. small glossy black soybeans and little black soybeans (glycine max) from china were purchased from a local vendor. they were authenticated by prof. shiuying hu, honorary professor of chinese medicine, the chinese university of hong kong (hong kong, china). the same isolation procedure and assay were employed for both cultivars. the beans were homogenized in distilled water. tris-hcl buffer (ph 7.4) was added to the dialyzed supernatant until the concentration of tris attained 10 mm. the supernatant was then loaded on a 5 cm×20 cm column of q sepharose (ge healthcare, hong kong, china) in 10 mm tris-hcl buffer (ph 7.4). after removing the unadsorbed fraction, adsorbed fractions (q1, q2 and q3) were eluted with starting buffer containing 0. 2, 0.5 and 1 m nacl, respectively. after examining the hemagglutinating effect of fractions q1−3, the lectin-enriched fraction q1 was dialyzed against 10 mm nh 4 oac buffer (ph 4.5) at 4 ºc, and then chromatographed on a 2.5 cm×20 cm column of sp sepharose (ge healthcare), which had previously been equilibrated with and was then eluted with 10 mm nh 4 oac buffer (ph 4.5). unadsorbed proteins were eluted with the buffer, and then adsorbed proteins were eluted stepwise with the same buffer containing 0.2 m nacl and 1 m nacl, respectively. the fraction eluted with 0.2 m nacl was then applied on a 1 ml mono q (ge healthcare) column in 10 mm nh 4 hco 3 buffer (ph 9). following elution of unadsorbed materials, adsorbed proteins (fraction s1, s2 and s3), were desorbed with two nacl concentration gradients (0−0.3 m and adsorbed proteins 0.3−1 m) in 10 mm nh 4 hco 3 buffer (ph 9). the adsorbed fraction (s2), which was eluted by approximately 0.2 m nacl, was the lectin-en-riched fraction. it was dialyzed, lyophilized and subjected to gel filtration on a superdex 75 hr 10/30 column (ge healthcare) using an akta purifier (ge healthcare) in 10 mm nh 4 hco 3 buffer (ph 9.4). the first eluted absorbance peak constituted purified lectin. molecular mass determination by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (sds-page) and by fast protein liquid chromatography (fplc)gel filtration sds-page was carried out in accordance with the procedure used by nielsen and reynolds [23] , using a 12% resolving gel and a 5% stacking gel. the gel was cast on the miniprotein set ii (bio-rad, shanghai, china). samples were diluted with sample loading buffer (10% glycerol, 0.4% sds, 0.005% bromophenol blue and 20 mm edta in 0.5 m tris-hcl, ph 7.5) followed by addition of 5% βmercaptoethanol. the samples were boiled in a water bath for 10 min. electrophoresis was performed at a constant current of 10 ma at room temperature. at the end of electrophoresis, the gel was stained with coomassie brilliant blue. fplc-gel filtration was carried out using a superdex 200 hr 10/30 column (ge healthcare) that had been calibrated with molecular-mass standards (ge healthcare). amino acid sequence analysis was carried out using an hp g1000a edman degradation unit and an hp 1000 hplc system from hewlett/packard (palo alto, usa) [20] assay of hemagglutinating activity in the assay for lectin (hemagglutinating) activity, a serial two-fold dilutions of the lectin solution in microtiter uplates (50 µl) were mixed with 50 µl of 2% suspension of rabbit red blood cells in phosphate-buffered saline (ph 7. 2) at 20 ºc. the results were recorded after about 1 h, when the blank containing only red cells had fully sedimented and appeared as a dot at the bottom of the well. the hemagglutination titer, defined as the reciprocal of the highest dilution exhibiting hemagglutination, is defined as one hemagglutination unit. specific activity is the number of hemagglutination units per mg protein [11] . the hemagglutinating inhibition tests to investigate inhibition of lectin-induced hemagglutination by various carbohydrates for 30 min at room temperature were performed in a manner analogous to the hemagglutination test [11] . serial two-fold dilutions of sugar samples were prepared in phosphate buffered saline. all of the dilutions were mixed with an equal volume (25 µl) of a solution of the lectin with 32 hemagglutination units. the mixture was allowed to stand for 30 min at room temperature, and then mixed with 50 µl of 2% rabbit erythrocyte suspension. the minimum concentration of the sugar in the final reaction mixture, which completely inhibited 32 hemagglutination units of the lectin preparation, was calculated. the effects of temperature and ph on hemagglutinating activity of the lectin were examined [11] . a solution of lectin was incubated at various temperatures (0, 10, 20, 30, 40, 50, 60, 70, 80, 90, and 100 °c) for 30 min. the tubes were then put on ice and assay of hemagglutinating activity was then carried out. a solution of lectin was incubated at various ph values (ph 1−14) for 30 min. the reaction mixtures in the tubes were neutralized and assay of hemagglutinating activity was then carried out. incubation of splenocytes from balb/c mice (20−25 g) was carried out at 37 ºc in a humidified atmosphere of 5% co 2 in the presence or absence of the lectin for 24 h in a 96-well culture plate. we added 10 µl (methyl-3 h) thymidine (0.25 µci; ge healthcare) before the splenocytes were incubated for another 6 h under the same conditions. the splenocytes were then harvested onto a glass fiber filter, and the radioactivity was measured [24−26] . tumor cells, mcf7 and hepg2, in their exponential growth phase were seeded into a culture plate and incubated for 3 h before addition of the lectin. incubation was carried out for another 48 h. radioactive precursor, 1 µci of (methyl-3 h)thymidine, was then added to each well and incubated for 6 h. the cultures were then harvested, and the incorporated radioactivity was determined [25] . the assay was carried out by using an enzyme-linked immunosorbent assay kit as described by collins et al [16] . the assay for hiv reverse transcriptase inhibitory activity was carried out in accordance with instructions supplied with the assay kit from boehringer mannheim (berlin, germany) since some antifungal proteins possess this activity. the assay takes advantage of the ability of reverse transcriptase to synthesize dna, starting from the template/primer hybrid poly(a) oligo(dt)15. the digoxigenin-and biotin-labeled nucleotides in an optimized ratio are incorporated into one of the same dna molecule, which is freshly synthesized by the reverse transcriptase (rt). the detection and quantification of synthesized dna as a parameter for rt activity follows a sandwich elisa protocol. biotin-labeled dna binds to the surface of microtiter plate modules that have been pre-coated with streptavidin. in the next step, an antibody to digoxigenin, conjugated to peroxidase, binds to the digoxigenin-labeled dna. in the final step, the peroxidase substrate is added. the peroxidase enzyme catalyzes the cleavage of the substrate, producing a colored reaction product. the absorbance of the sample at 405 nm can be determined using a microtiter plate reader and is directly correlated to the level of rt activity. a fixed amount (4− 6 ng) of recombinant hiv-1 reverse transcriptase was used. the inhibitory activity of the lectin was calculated as percent inhibition as compared to a control without the lectin [27] . the assay of hiv-i integrase and severe acute respiratory syndrome (sars) proteinase activities was conducted as previously reported [28] . hiv-1 integrase assay a non-radioactive elisa-based hiv-1 integrase assay was performed according to the dna-coated plate method. in this study, 1 µg of smailinearized pbluescript sk was coated onto each well in the presence of 2 m nacl as target dna. the donor dna was prepared by annealing vu5br (5'-biotin-gtgtggaaaatctctagcagt-3') and vu5 (5'-actgctagagattttccacac-3' ) in solution containing 10 mm tris-hc1, ph 8.0, 1 mm edta and 0.1 m nacl at 80 ºc followed by 30 min at room temperature. integrase reaction was performed in 20 mm hepes (ph 7.5) containing 10 mm mncl 2 , 30 mm nacl, 10 mm dithiothreitol and 0.05% nonidet-p40 (sigma, st. louis, usa). after the integrase reaction, the biotinylated dna immobilized on the wells was detected by incubation with streptavidin-conjugated alkaline phosphatase (boehringer mannheim), followed by colorimetric detection with 1 mg/ml p-nitrophenyl phosphate in 10% diethanolamine buffer (ph 9.8) containing 0.5 mm mgcl 2 . the absorbance of each well due to the alkaline phosphatase reaction was measured at 415 nm. screening for inhibitory effect on sars coronavirus (cov) protease the activity of sars cov protease was indicated by a cleavage of designed substrate which was composed of two proteins linked by a cleavage site for sars cov protease. the reaction was performed in a mixture containing 5 µm sars cov protease, 5 µm sample, 20 µm substrate and buffer (20 mm tris-hcl, ph 7.5, 20 mm nacl and 10 mm beta-mercaptoethanol) for 40 min at 37 ºc. after 40 min, the reaction was stopped by heating at 100 ºc for 2 min. then the reaction mixture was analyzed by sds-page. if sars cov protease is inhibited by the test sample, there is only one band, which is the intact substrate, shown in sds-page. the crude extract of small glossy black soybeans was fractionated on a q sepharose column into an unadsorbed fraction and three adsorbed fractions (q1, q2 and q3) were obtained by stepwise elution with 0.2, 0.5 and 1 m nacl in tris-hcl buffer [ fig. 1(a) ]. hemagglutinating activity was confined to fraction q1. this fraction was resolved on an sp sepharose column into an unadsorbed fraction and two adsorbed fractions (sp1 and sp2) respectively when eluted with 0.2 m nacl and 1 m nacl in the nh 4 oac buffer [ fig. 1(b) ]. hemagglutinating activity resided in the smaller fraction sp1. fraction sp1 was further resolved by ion exchange chromatography on an fplc-mono q column into a tiny unadsorbed fraction and several adsorbed fractions [ fig. 1(c) ]. hemagglutinating activity was recovered only in fraction s2, which was subsequently separated on a superdex 75 column into a sharp larger fraction and a smaller fraction. activity was detected only in the larger fraction [ fig. 1 (d) ]. from chinese little black soybeans, a lectin was isolated using the same procedure except for the omission of ion exchange chromatography on mono q (fig. 2) . the small glossy black soybean lectin product appeared as a single band with a molecular mass of 25 kda in sds-page (fig. 3) , and exhibited a single peak with a molecular mass of 50.2 kda in gel filtration on superdex 75 [ fig. 1(d) ]. the little black soybean lectin appeared as a single band with a molecular mass of 31 kda in sds-page (fig. 3) , and exhibited a single peak with a molecular mass of 62 kda in gel filtration on superdex 75 [ fig. 2(c) ]. the small glossy black soybean lectin was obtained with a specific activity of 7168 u/mg and a purification fold of 29 ( table 1 ). the n-terminal sequence of the lectin was 1 aetvsfswnkfvpkq 15 , which was identical to lectin from yellow soybean and similar to partial sequences near the n-terminals of medicago sativa ( 27 aettsfs-itkfvpdq 41 ) and robinia pseudoacacia lectins ( 35 esvsfsftkfvp 46 ). there was only one peak in every sequencing cycle, indicating that the lectin preparation was homogeneous. it appears that soybean lectins are similar in n-terminal sequence to only some members of the pea family fabaceae. the n-terminal sequence of little black soybean lectin was identical to that of small glossy black soybean lectin ( table 2) . determination of sugar specificity, ph stability and thermostability of hemagglutinating activity melibiose, arabinose, raffinose and galactose at 40 mm concentration inhibited the hemagglutinating activity of the small glossy black soybean lectin. however, glucose, fucose, rhamnose, mannose, lactose, xylose, glucuronic acid, polygalacturonic acid, and mannosamine had no effect ( table 2 ). the hemagglutinating activity was stable after exposure for 30 min to the ph range 3−12 and the temperature range 0−70 ºc. the carbohydrate specificity of little black soybean lectin was identical to that of small glossy black soybean lectin. the hemagglutinating activity of little black soybean lectin was stable only up to 40 ºc for 20 min, but the small glossy black soybean lectin was stable up to 70 ºc for 30 min. the small glossy black soybean lectin inhibited proliferation of hepg2 cells and mcf7 cells with an ic 50 of 4.1 µm and 2.6 µm, respectively (fig. 4) and the activity of hiv-1 reverse transcriptase with an ic 50 of 2.82 µm (fig. 5) . chromatographic glucose, fucose, rhamnose, mannose, lactose, xylose, glucuronic acid, polygalacturonic acid, and mannosamine were all inactive when tested in 500 mm. +, inhibition of hemagglutinating activity of lectin; −, no inhibition of hemagglutinating activity of lectin. the mitogenic activity of the lectin on mouse splenocytes is shown in fig. 6 . both the lectin and con a stimulated maximal mitogenic response at similar concentrations. however, the maximal response achieved by small glossy black soybean lectin was weaker than that evoked by con a (fig. 6) . small glossy black soybean lectin did not inhibit hiv integrase or sars proteinase when tested up to 20 μm (data not shown). the little black soybean lectin inhibited hiv-1 reverse transcriptase with an ic 50 of 3.54 μm (fig. 5) . the maximal mitogenic response that both the small glossy black soybean lectin and the little black soybean lectin elicited was about 20% of the maximal response to con a. the maximal mitogenic response was achieved by similar concentrations of small glossy black soybean lectin, little black soybean lectin and con a (fig 6) . a comparison of the characteristics of the two black soybean lectins isolated in this study with those of soybean lectins is presented in table 3 . the two chinese small glossy black soybean lectins differ somewhat from common yellow soybean lectin (hereinafter referred to as soybean lectin) in carbohydrate specificity. soybean lectin is galactose-specific [13] , whereas chinese black soybean lectins are melibiose-specific although the latter two are also galactose-specific. the two chinese black soybean lectins potently inhibit hiv-1 reverse transcriptase (ic 50 about 2.8 µm). it is known that some lectins exhibit hiv-1 reverse transcriptase inhibitory activity and inhibit hiv replication [27, 29, 30] . however, just like the french bean defensin [28] , the two black soybean lectins are devoid of hiv-1 integrase inhibitory and sars proteinase inhibitory activity. the antiproliferative and anti-tumor activities of lectins are well documented [25,27,31−33] . chinese small glossy black soybean lectin exerts potent antiproliferative activity toward hepg2 and mcf7 cells, with an ic 50 of 4.1 µm and 2.6 µm, respectively. both black soybean lectins manifest weaker mitogenic activity than con a toward splenocytes. this is in line with findings on other lectins [24, 25] . the mitogenic activity of soybean lectin toward human and murine lymphocytes is enhanced after polymerization by physical or chemical means [34] . soybean lectin has immunomodulatory and anti-tumor actions [34] . natural suppressor cells from the spleen and cyclophosphamide-generated suppressor cells react specifically with soybean lectin and can thus be isolated by agglutination from the bone marrow [35, 36] . soybean lectin is employed for purging the marrow of t cells during treatment of acute lymphoblastic leukemia in order to decrease the risk of graft-versus-host disease [37] ; soybean lectin reacts with and eliminates cancer cells from the marrow [38] . this investigation's findings on the two black soybean lectins' mitogenic activity towards splenocytes and their antiproliferative activity toward tumor cells are consistent with previous observations [34, 38] . an anti-tumor action mechanism of soybean lectins has been proposed involving the action of the lectins on tumor cell membranes, the reduction of tumor cell proliferation, the induction of tumor-specific cytotoxicity of macrophages, and apoptosis. thus, tumor cells are more susceptible to attack by macrophages after treatment with lectins. furthermore, lectins exert an immunomodulatory effect on altering interleukins production [39] . soybean lectin reportedly reacts preferentially with some rumen fungi [40] , but an antifungal action has not been demonstrated. likewise, the two black soybean lectins are devoid of antifungal activity (data not shown). the lectins started to evoke a mitogenic response at a lower concentration than con a although the maximal response was much smaller in magnitude. in fact, to date, only a handful of lectins have been reported with antifungal activity [41, 42] . small glossy black soybean lectin has fair ph stability and thermostability. its hemagglutinating activity is preserved in the ph range 3−12 and in the temperature range 0−70 ºc. little black soybean lectin is stable in the ph range 3−12 and in the temperature range 0−40 ºc. yellow soybean lectin is active in the ph range 3−12 and in the temperature range 0−50 ºc. french bean lectin is stable in ph range 4−10 and in the temperature range 0−90 ºc [30] . hence the french bean lectin and small glossy black soybean lectin appear to be similar in stability. the protocol employed in the present investigation for purifying the two black soybean lectins entailed successive ion exchange chromatography on q sepharose, sp sepharose and mono q (with the exception of little black soybean lectin), and gel filtration on superdex 75. french bean lectin was isolated using a similar procedure involving chromatography on sp sepharose, affi-gel blue gel, q sepharose and superdex 200 [28] . the two black soybean lectins were adsorbed on sp sepharose and q sepharose. thus, the three leguminous lectins appear to have similar chromatographic behavior. a 29-fold purification was obtained in the present study for small glossy black soybean lectin compared to 10-fold purification in the case of french bean lectin [28] . thus lectins from the two cultivars of chinese black soybean appear to differ in subunit molecular mass, thermostability and mitogenic activity, although they share the same n-terminal amino acid sequence and carbohydrate specificity and have similar hiv-reverse transcriptase inhibitory activity. this finding is reminiscent of the observation that lectins from different cultivars of the bean phaseolus vulgaris, such as the pinto bean [24] , haricot bean [25] , red kidney bean [30] , and dark red kidney bean [26] , have similar but not identical n-terminal sequences. their other characteristics, including carbohydrate specificity and antiproliferative activity toward tumor cells, may not be all alike [24] [25] [26] 30] . the results of the present investigation indicate that different soybean cultivars produce lectins that are not identical. the lectins isolated in the present study are characterized by potent antiproliferative activity toward cancer cells and inhibitory activity against hiv-1 reverse transcriptase, as well as moderate ph stability and thermostability. its antiproliferative activity against cancer cells of mammalian origin and hiv-1 reverse transcriptase inhibitory activities indicate that it is a defense protein. this is in line with the defense function of lectins in plants [43] . as such, the biological activities of black soybean lectins are potentially exploitable in medicine. isolation and characterization of two korean mistletoe lectins isolation and characterization of l-rhamnose-binding lectin, which binds to microsporidian glugea plecoglossi, from ayu (plecoglossus altivelis) eggs identification and characterization of an intracellular lectin, calnexin, from aspergillus oryzae using n-glycan-conjugated beads structural basis for mannose recognition by a lectin from opportunistic bacteria burkholderia cenocepacia a tuber lectin from arisaema jacquemontii blume with anti-insect and anti-proliferative properties purification of a lectin from eugenia uniflora l. seeds and its potential antibacterial activity antitumor effect of plant lectins the role of galectins in the initiation, amplification and resolution of the inflammatory response the role of dectin-1 in antifungal immunity pu r i fi ca t ion a nd char a ct er i zat i on of a n nacetylglucosamine-binding lectin from koelreuteria paniculata seeds and its effect on the larval development of callosobruchus maculatus (coleoptera: bruchidae) and anagasta kuehniella (lepidoptera: pyralidae) isolation and characterization of a glucose/ mannose-specific lectin with stimulatory effect on nitric oxide production by macrophages from the emperor banana the biochemical and functional food properties of the bowman-birk inhibitor purification of soybean agglutinin by affinity chromatography on sepharose-n-epsilonaminocaproyl-β-d-galactopyranosylamine complete amino acid sequence of soybean leaf p21: similarity to the thaumatinlike polypeptides does the effect of soy phytoestrogens on bone in postmenopausal women depend on the equol-producing phenotype? isoflavones, equol and cardiovascular disease: pharmacological and therapeutic insights suppressing effects of dietary supplementation of soybean trypsin inhibitor on spontaneous, experimental and peritoneal disseminated metastasis in mouse model the great dictionary of chinese medicine sativin: a novel antifungal miraculinlike protein isolated from legumes of the sugar snap pisum sativum var. macrocarpon purification and characterization of novel ribosome inactivating proteins, alpha-and beta-pisavins, from seeds of the garden pea pisum sativum a stable trypsin inhibitor from chinese dull black soybean with potentially exploitable activities a b owma n-b i r k t r ypsi n i nhi bi tor wi t h antiproliferative activity from hokkaido large black soybeans measurements of molecular weights by gel electrophoresis purification and characterization of a galactose-specific lectin with mitogenic activity from pinto beans a h om o te tr a me r i c a gg lu ti n in w it h antiproliferative and mitogenic activities from haricot beans a hemagglutinin with mitogenic activity from dark red kidney beans purification of a trypsin-stable lectin with antiproliferative and hiv-1 reverse transcriptase inhibitory activity isolation of a homodimeric lectin with antifungal and antiviral activities from red kidney bean (phaseolus vulgaris) seeds primary structure and carbohydrate binding specificity of a potent anti-hiv lectin isolated from the filamentous cyanobacterium oscillatoria agardhii concurrent purification of two defense proteins from french bean seeds: a defensin-like antifungal peptide and a hemagglutinin a soybean kunitz trypsin inhibitor suppresses ovarian cancer cell invasion by blocking urokinase up-regulation mistletoe lectin induces apoptosis and telomerase inhibition in human a253 cancer cells through dephosphorylation of akt plant lectins as inhibitors of tumor growth and modulators of host immune response enhancement of the biological activities of soybean agglutinin by cross-linking with glutaraldehyde soybean agglutininpositive natural suppressor cells in mouse bone marrow inhibit interleukin 2 produ ction and utilization in mixed lymphocyte reactions heterogeneity of splenic natural suppressor cells induced in mice by treatment with cyclophosphamide transplantation for acute leukaemia with hla-a and b nonidentical parental marrow cells fractionated with soybean agglutinin and sheep red blood cells differential agglutination by soybean agglutinin of human leukemia and neuroblastoma cell lines: potential application to autologous bone marrow transplantation the anticarcinogenic potential of soybean lectin and lunasin fate of the antinutritive proteins of soyabean in the ovine gut antifungal properties of lectin and new chitinases from potato tubers h nmr study of the interaction of n, n',n''-triacetyl chitotriose with ac-amp2, sugar binding antimicrobial protein isolated from amaranthus caudatus lectins as plant defense proteins key: cord-288710-fweorzis authors: marchand, aixa d.; anyiwo, nkemka u. title: contextual factors shaping diverse political action: a commentary on the special issue on adolescent political development date: 2020-10-14 journal: j appl dev psychol doi: 10.1016/j.appdev.2020.101212 sha: doc_id: 288710 cord_uid: fweorzis this timely special issue on political development broadens the empirical conversation around how adolescents are engaging politically and civically, what factors shape their involvement, how their involvement impacts their wellbeing, and how to engage diverse populations of youth in the political system. from the perspectives of critical consciousness and sociopolitical development, we reflect on two themes in particular: the importance of context and the various ways in which political development and involvement is conceptualized and defined. we conclude with suggestions for future empirical work and implications for policy and practice. this special issue takes up the important and timely topic of political socialization and development with a focus on how to engage diverse populations of youth in the political system. currently america is fighting two pandemics, one of covid-19 and the other of institutional racism. in this critical historical moment, we are presented with a new opportunity to include youth voices as we reimagine how to progress as a society. a strong democracy is created when all perspectives and voices are included in the political process. especially, with youth, there is great potential for the development of novel ideas and social change when their voices are heard and valued (watts & flanagan, 2007) . even more specifically, given documented disparities in political participation by gender, race, and socioeconomic status (coffé & bolzendahl, 2010; verba, burns, & schlozman, 1997; ) , it is imperative for us as scholars to understand ways to engage those who have been disenfranchised. with the 2020 presidential election on the horizon, understanding the mechanisms and contextual factors that influence youth's action and participation is of paramount importance. the implications of the work presented in this special issue suggest important pathways and imperatives of how to bolster political development and action for youth in america and provide insight on directions for future empirical work. a key consideration includes a need to better understand the political experiences of youth who have been historically marginalized and barred from full participation in the political system, especially in the context of national systemic racial reckoning (anyiwo, palmer, garrett, starck, & hope, 2020; hart, atkins, & donnelly, 2004; wray-lake et al., 2018) . therefore, the body of work presented in this special issue reinforces the realities that in order for our democracy to thrive, there needs to be shifts in the political system to allow for a diversity of representation and engagement from its citizens. taken together these 7 papers contribute to the field of civic and political engagement and fill gaps in the literature by focusing on youth from varying regions, various racial/ethnic backgrounds, and political perspectives that have historically been understudied in psychological research and underrepresented in the political process. in addition to their conceptual and theoretical contributions, these papers are methodologically diverse and contribute to the study of political socialization using planned missing data, large panel samples, semi-structured interviews, participant observations, and public records. we are delighted to have been invited to provide our commentary on the papers that make up this special issue. we read these papers through a lens of the current sociopolitical moment as well as through our own research interests and offer our experiences and points of view. as a scholar who focuses on black parent school engagement and understandings of educational inequities and with expertise in both psychology and education (aixa marchand), i am particularly drawn to the bowyer and kahne (2020) article that emphasizes the importance of providing varied types of learning opportunities to students and its relation to increasing political engagement in youth. additionally, as a scholar focused on the cultural factors that shape black youth's healing and empowerment (nkemka anyiwo), i am drawn to hope, smith, cryer-coupet, and briggs's (2020) examination of the impact of black youth's experiences of racial discrimination stress on multiple dimensions of their critical consciousness. https://doi.org/10.1016/j.appdev.2020.101212 received 1 october 2020; accepted 7 october 2020 as scholars of critical consciousness (aixa marchand) and sociopolitical development (nkemka anyiwo), with mutual interests in racial socialization messages, we analyze these papers through the lens of these pertinent theories in order to identify the contributions the special issue offers to the body of literature on political development and socialization. although critical consciousness (cc) and sociopolitical development (spd) are often discussed as separate theories, in line with early theoretical work, we discuss cc as a process nested in spd. cc has been described as an "antidote for oppression" and as "armor" that is psychologically protective against the oppressive societal systems in which youth of color reside (seider & graves, 2020; watts, griffith, & abdul-adil, 1999) . originally conceptualized by paulo freire, cc is the analysis of the social conditions that one lives in and the action to change inequities observed and experienced (freire, 1970) . current conceptualization of cc consists of three subcomponents: critical reflection, critical agency, and critical action (diemer, rapa, park, & perry, 2017; watts, diemer, & voight, 2011) . within critical action exists political behaviors such as voting, writing letters to legislators, and social change behaviors s such as participating in marches and signing petitions (diemer et al., 2017) . cc can be nested into a broader theory of spd, which examines the processes by which youth develop the knowledge, emotional faculties, and critical thinking skills to analyze and contest inequitable systems (watts, williams, & jagers, 2003) . given the limited social and political power that youth who are under the age of 18 have in society, their ability to engage in action is theorized to be influenced by the extent to which they have meaningful opportunities to engage in action with mentorship and support from adults, also known as opportunity structures (watts & flanagan, 2007) . research has presented mixed results about the ways that components of spd may function as an antecedent to civic and political participation, whether conventional or unconventional. some studies find ethnic and racial variations in the sociopolitical pathways to action (diemer & rapa, 2016) . further, limited empirical work has examined the role of opportunity structures in facilitating action. as described by diemer and rapa (2016) , there is still a lack of clarity on the "ontogenesis" of cc and spd. thus, the current special issue presents a body of work that can serve to further the field's understanding of the precedents and antecedents of youth's political engagement. in this commentary, we consider gaps in the literature that are partially addressed by these current studies and identify future directions to progress the field. our analysis of the literature has identified two common themes across the papers in this special issue: 1) the importance of context in the political action of youth, and 2) the dynamic manifestations of political engagement. given the current sociopolitical climate and our scholarship which focuses on black youth and families, our recommendations for future research and policy are geared to youth who are historically racially marginalized. the articles within this special issue pay special attention to the dynamic nature of the interactions between individuals and their contexts, both physical and social. lerner, wang, champine, warren, and erickson (2014) posit that civic engagement develops through bidirectional interactions between the interpersonal and social contexts. in other words, participation and engagement must recognize the broader ecology of human development. including the varying levels of systems of influence is necessary to gain a more nuanced and full understanding of what supports and fosters political development (bronfenbrenner & morris, 2007) . because of the varying combinations and intersections of individuals and contexts, it is imperative for research to explore the numerous trajectories that lead to positive civic engagement and social action outcomes for diverse youth. metzger, alvis, and oosterhoff (2020) presents to readers the importance of understanding geographical and contextual barriers and supports that influence youth civic participation. they found that adolescents who live in rural areas may differ from those who live in city contexts in their views of civic responsibility and efficacy. they also examine socioeconomic status and explore the intersections between geographic context and parents' socioeconomic status. their work found that rural youth and youth who live in city contexts differed in their ratings of how much social praise was associated with political activity and how important and obligatory they believed it to be. together, these findings help us understand how context shapes youths' individual views of themselves as effective political actors. these results shed light on the differing political concerns for youth living in different regions and communities that are facing different issues. however, with a sample of youth who predominantly identify as white, further research should examine how racial marginalized youth who reside in rural areas view civic responsibility and their civic efficacy. for example, most empirical work with black adolescents has been conducted in urban areas with little consideration of the experiences of rural residing youth. qualitative research has noted that black rural communities may be detrimentally affected by the lack of economic resources in comparison to their suburban and urban and suburban counterparts, but conversely may benefit from collective socialization, or strategies to support other parents and monitor and guide children in the neighborhood (berkel et al., 2009; burton & jarrett, 2000) . with awareness of these positive and negative contextual factors that influence rural black adolescent outcomes, further exploration of how these factors may impact youth political participation will help delineate ways to foster their political engagement. mcdevitt and hopp (2020) use panel study data to explore political identity in counter-attitudinal climates. by counter-attitudinal they are referring to potentially confrontational and adversarial interactions. they found that in dissonant climates in battleground states, democrat identifying youth were more likely to disagreeing openly, initiating conversation, and testing opinions. this aligns with prior research that has found that environments with diverse perspectives and contentious discussions can serve as an optimal environment for youth to develop their political views and engage in action (hess, 2009) . their work reminds us that engaging with others who may have dissenting perspectives and learning to manage and resolve disagreements are important in fostering democracy. hess (2009) asserts that schools are the optimal place for this to happen and that teachers should not shy away from controversial topics but rather promote an understanding that dissent is a foundational part of civic life. while engaging with people who have different views may strengthen youth's political understanding and motivate their action, future work may consider how politically deviant contexts may function differently for youth of color. indeed, political ideologies are often grounded in racial ideologies and can be rooted in racial bias as evident by the concurrent rise of the white supremacy movement with the rise of president donald trump (tatum, 2017) . thus, for youth of color, dwelling in spaces with contentious political ideologies may present psychological and even physical danger. adults such as educators and mentors may play a large role in the political development and socialization of youth. in a longitudinal study of five charter schools all following different schooling models, seider and graves (2020) explore the ways in which pedagogical practices and educators foster a sense of cc of racial injustice and a development of a commitment to critical action. their findings speak to the importance of educational spaces to offer learning opportunities promoting civic engagement and political activity. the bowyer and kahne (2020) article in this special issue takes on this exact issue of assessing the ways in which intentional civic education may impact learning opportunities. by examining panel data collected in chicago public schools, they found that teaching about sharing perspectives led to more online political participation, but that teaching about evaluating online content reduced online political participation. further, teaching about offline civic engagement has a positive relationship with subsequent offline civic engagement. these findings indicate that schools continue to play a role in establishing participatory norms among students and play an important socializing agent. further, these results point to the benefit of having a dedicated commitment to fostering civic engagement, as chicago public schools has done by promoting civic education on a district level and requiring that high school students take a semester long civics course (bowyer & kahne, 2020) . hope et al. (2020) help us better understand how the social context, in this case different forms of racism, affect black adolescents' cc development. as mentioned, cc is theorized in three dimensions, critical reflection, critical agency, and critical action (diemer & rapa, 2016; watts et al., 2011) . black youth's experiences with individual and cultural racism are associated with more critical reflection and critical agency, while all types of racial stress (individual, cultural, and institutional) are indirectly associated with higher levels of critical action. these findings in conjunction with theoretical work highlighting the importance of racial sociocultural processes, such as racial identity, parent socialization, and discrimination represent the necessity to further explore how youth experiences both personally and vicariously may impact their political behaviors and engagement (anyiwo, bañales, rowley, watkins, & richards-schuster, 2018) . involvement in the political process is multidimensional. there are various ways that youth can choose to engage and these articles push our thinking about what is considered political engagement, what influences it, and how it affects participants. definitions of civic and political engagement have become increasingly inclusive and recognize both the "conventional" and "social-cause" efforts to help others, improve the community, and/or shape the future of society both at an individual and collective level (adler & goggin, 2005; anyiwo, palmer, et al., 2020; torney-purta, lehmann, oswald, & schulz, 2001) . further, civic and political engagement for youth encompasses the behaviors and actions they are participating in to make social and political change which include: volunteering for political campaigns, community organizing, writing, and signing petitions, activism, and joining civil rights organizations (diemer et al., 2017; gaby, 2017; watts & flanagan, 2007) . shifts in what constitutes this engagement enables us to examine these political processes within youth samples. youth often have not been considered within political spaces, because engagement has generally been conventionally conceptualized as voting, volunteering, and donating to political campaigns-activities that are largely inaccessible.to youth in the united states below the age of eighteen. however, even without the legal ability to vote and contribute to our democracy in that way, youth are active and contributing socially and politically. by using definitions and measures that are inclusive of activities that youth are participating in, we can get a better sense of how they are engaging within the political system. in their study on college students, ballard, ni, and brocato (2020) paper describes diverse manifestations of action. they conceptualize traditional/standard political behaviors as actions that occur within existing political systems (e.g., voting, joining political groups) and "non traditional" political behaviors as actions oriented towards resisting existing political systems. within what is considered nontraditional political behaviors includes activism (e.g., protesting) and expressive forms of action (e.g., wearing shirts with a social message). engagement in the political system may manifest differently for youth of color. ballard et al. (2020) work points to this as they have conceptualized membership in a cultural and ethnic organization as a form of political behavior. in future work, it is important to consider the motivations behind youth's engagement in political action. for example, historically marginalized youth may use "traditional" action as a tool for resistance against systems by engaging with and pursuing leadership systems that have historically disenfranchised them. similarly, youth may use nontraditional action to advocate for the sustenance of oppressive systems as illustrated by white supremacist protests. recent measurements have assessed the diverse ways that racially marginalized youth or youth advocating for racial justice may engage in individual or collective action (aldana, bañales, & richards-schuster, 2019; hope, pender, & riddick, 2019) . future work may use qualitative inquiry to excavate the different forms of action that youth engage in and the ideologies that drive these variations. the influence of adults on youth political socialization and development is only lightly covered in this special issue. terriquez, villegas, villalobos, and xu (2020) report that vertical socialization (from adult to youth) is not as impactful as horizontal socialization (peer to peer) and even may suppress participation in political action in some instances. in their sample of latinx youth who are predominantly children of immigrants, these results make intuitive sense. research has found that undocumented immigrants may avoid contact with social institutions out of fear immigration law enforcement (blewett, smaida, fuentes, & zuehlke, 2003 . o'leary & sanchez, 2011 . this fear may explain why parents who are undocumented may dissuade their children from participating in the political process that requires them to interact with systems in society more broadly (cross et al., 2020) . prior work exploring latinx adolescents' reaction to trump immigration policies found that youth in their study reported greater participation in civic activities such as voting, voter-registration, attending political rallies, and protests (wray-lake et al., 2018). the terriquez et al. (2020) paper in conjunction with the mcdevitt and hopp (2020) paper help further explain and provide support for the increase in civic engagement that wray-lake et al. (2018) found. latinx youth in the terriquez et al. (2020) study reside in the central valley area of california that is largely conservative and anti-immigrant. these dominant perspectives create a potential hostile context where youth are encountering adults who voice opinions counter to their own. connecting back to the mcdevitt and hopp (2020) article, they found that democratic youth thrive when in counter-attitudinal climates suggesting the important ways regional ideological climates may impact on youth's political engagement and action. although the results from the terriquez et al. (2020) article suggest that vertical forms of political socialization from parents and school educators may not encourage latinx youth to be politically active, further exploration with parents from other backgrounds is needed. trust between individuals and systems is an important initial consideration. a prerequisite for trust is the belief and understanding that institutions are trustworthy and "procedurally just" (yeager, purdie-vaughns, hooper, & cohen, 2017) . documented social injustices that black americans in the country have faced for 400 years may lead to feelings of distrust in systems within society. for instance, black parents' experiences with racism in societal systems may introduce feelings of reticence to engage due to perceptions of or prior experiences with discrimination and alienation (marchand, vassar, diemer, & rowley, 2019; wilson-cooper, 2009 ). parents' engagement and willingness to engage with the political system may serve as a model for their children. if parents view the system as contentious and off-putting, it may model for their children to be weary and disengage in conventional political actions. therefore, future work exploring how black parents' actions play a role in their children's political development and engagement is necessary to further understand how to foster political development and engagement in black youth. although not specifically focused on parent action or youth action, prior work has documented how black parents' beliefs and actions about societal inequities are related to their children's attributions about the achievement gap, a form of cc about educational equity (bañales et al., 2020) . although this paper did not focus on adolescents' action or political development, it lays the foundation for expecting a relationship between parents' perspectives and their adolescent child's view about society. bañales et al. (2020) explore parental messages of racial socialization as a precursor of beliefs about racism and the blackwhite achievement gap. these racial socialization messages from parents often cover and allude to the oppressive systems of race in this nation and develop a sense of critical reflection in youth of color. a wealth of research has shown that critical reflection of perceived inequality is associated with civic action (diemer & rapa, 2016; hope et al., 2020) , therefore providing nascent evidence that parent racial socialization messages may affect political engagement in their children (anyiwo et al., 2018) . examining the influence of other adults such as teachers and mentors in sociopolitical development is also an important next step in the field. scholars have identified intergenerational communal relationships between adults and youth as fostering youth's sociopolitical action ability to heal through critical resistance (ginwright, 2007) . when youth organize with the mentorship of adults, they can build skills in political engagement which will support them in feeling more efficacious to do so in the future. bowyer and kahne (2020) show the promise that online and offline civic learning opportunities have for youth engagement. an important consideration that these articles take up is that political engagement and action might have both benefits and costs to youth that need to be further understood (ballard et al., 2020) . the psychosocial impact of political engagement may also vary depending on types of engagement and by racial/ethnic group. ballard et al. (2020) found that traditional political behaviors were associated with positive indicators of wellbeing while activism and expressive forms of political behavior were adversely related to well-being. although these associations were weak, they may exist because expressive forms of engagement are more related to affect and emotion and spur from emotional moments. however, while there were associations between political engagement and wellbeing for youth from racial/ethnic backgrounds, there were no associations for black youth. previous work has also among black and latinx students in associations between their political engagement and wellbeing (e.g., hope, velez, offidani-bertrand, keels, & durkee, 2018) . in the current special issue hope et al. (2020) found that black youth's experiences of racial stress was associated with their cc, highlighting that youth may be coping with racism through the process of critical reflection, building their agency, and participation in critical action. further, in qualitative work, youth of color identify political and community organizing as therapeutic (ortega-williams, wernick, debower, & brathwaite, 2020) . the differential findings in the field reflect a need to explicate the factors that may shape psychological implications of action on mental health and clarify the extent to which different forms of action yield different psychological outcomes for youth (anyiwo, palmer, et al., 2020) . ballard et al.'s (2020) assessment of expressive action includes youth's expression online, which particularly, in the global pandemic, is a fruitful space for sociopolitical action and change. thus, future work should more deeply identify implications of digital forms of action on the wellbeing of youth. the body of work discussed in this special issue has significant implications for policy and practice. educators, policy makers, and practitioners should be aware of the ways that context may differentially shape youths' engagement in various political and civic actions, beliefs about their civic responsibilities, and perceptions of their own efficacy. those in decision making positions can utilize the results presented in this special issue to inform their policy choices. findings from hart, allred, and atkins (2020) paper point to evidence that lowering the voting age does not indicate that youth unequivocally take on their parents' partisan identifications. lowering the voting age is an important consideration moving forward for many reasons: it can politically mobilize and engage an age cohort whose voice has largely been absent in decisions making spaces and may contribute to an increase long-lasting political representation across the lifespan (coppock & green, 2016) . given that we observe documented disparities in political action, there is a need to further unpack the causes of these disparities. for example, these disparities might occur by function of structural barriers that constrain access to opportunity structures in general and to political participation such as access to voting, in particular. historically voter suppression has marginalized black communities and communities of color from fully participating in the political process, and more recently we have seen blatant actions such as moved mailboxes and closed polling locations. therefore, policy makers should be informed of the myriad barriers youth and especially youth of color may face when instituting policy decisions. the current special issue offers important considerations for programmatic efforts and clinical work with youth. schools may play a significant role in cultivating youth's political engagement on and offline (bowyer & kahne, 2020) . thus, educators should consider how different pedagogical strategies such as engaging in debate or dialogue with dissenting perspectives (mcdevitt & hopp, 2020) or supporting youth in sharing and evaluating perspectives (bowyer & kahne, 2020) can shape how youths' sociopolitical engagement. the studies highlight the importance of considering the unique experiences of youth in identifying how best to support them. for example, youth in different locales may vary in their perspectives about political engagement and thus, programmatic efforts may need to be tailored to the unique needs and experiences of urban, rural, and suburban youth (metzger et al., 2020) . youth, particularly those from backgrounds that have been historically marginalized, may engage in the analysis of injustice and participate in action to contest injustice as a mechanism to cope with the stresses associated with discrimination . nevertheless, youth's engagement in resistance against political systems may be adversely associated with their psychology wellbeing (ballard et al., 2020) . thus, youth advocates should consider engaging clinicians in their programmatic advocacy work with youth and consider integrating content in curricula aimed to support youth psychologically and emotionally as they engage social change. as barber (2003) reminds us, a "strong democracy" is one where participants not only are spectators who vote, but rather promote the type of society they wish to see by expressing their views and being active in their community. youth have a unique perspective in that they can envision a world that is more just and equitable for all (flanagan, 2013) . the political habits of youth set the foundation for their future participation in adulthood, therefore by creating spaces where youth can engage could have a long-term impact of increased civic participation (coppock & green, 2016) . especially in the current moment-the movement for black lives and the continued fight for racial and social justice, it is crucial that as researchers, practitioners, and educators we find ways to listen to youth voice and support their political engagement in order to ensure our democracy functions as it was designed and that our generation leave the world better for those who will follow. what do we mean by "civic engagement youth anti-racist engagement: conceptualization, development, and validation of an anti-racism action scale sociocultural influences on the sociopolitical development of african american youth racial & political resistance: an examination of the sociopolitical action of racially marginalized youth political engagement and wellbeing among diverse college students black adolescents' critical reflection development: parents' racial socialization and attributions about race achievement gaps strong democracy: participatory politics for a new age it takes a village: protecting rural african american youth in the context of racism health care needs of the growing latino population in rural america: focus group findings in one midwestern state the digital dimensions of civic education: assessing the effects of learning opportunities the bioecological model of human development. handbook of child psychology in the mix, yet on the margins: the place of families in urban neighborhood and child development research same game, different rules? gender differences in political participation is voting habit forming? new evidence from experiments and regression discontinuities illuminating ethnic-racial socialization among undocumented latinx parents and its implications for adolescent psychosocial functioning unraveling the complexity of critical consciousness, political efficacy, and political action among marginalized adolescents development and validation of the critical consciousness scale teenage citizens: the political theories of the young pedagogy of the oppressed the civic engagement gap(s): youth participation and inequality from 1976 to black youth activism and the role of critical social capital in black community organizations stability and change in partisan political identification: implications for lowering the voting age psychological and socio-structural influences on involvement in volunteering controversy in the classroom: the democratic power of discussion development and validation of the black community activism orientation scale relations between racial stress and critical consciousness for black adolescents political activism and mental health among black and latinx college students development of civic engagement: theoretical and methodological issues integrating race, racism, and critical consciousness in black parents' engagement with schools democratic youth in counter-attitudinal election climates: a test of the conflict-seeking hypothesis adolescent civic responsibility and civic efficacy: differences by rurality and socioeconomic status anti-immigrant arizona: ripple effects and mixed immigration status households under "policies of attrition" considered finding relief in action: the intersection of youth-led community organizing and mental health in brooklyn schooling for critical consciousness: engaging black and latinx youth in analyzing, navigating, and challenging racial injustice. 8 story street first floor why are all the black kids sitting together in the cafeteria?: and other conversations about race the political socialization of latinx youth in a conservative political context citizenship and education in twenty-eight countries: civic knowledge and engagement at age fourteen international association for the evaluation of educational achievement knowing and caring about politics: gender and political engagement critical consciousness: current status and future directions pushing the envelope on youth civic engagement: a developmental and liberation psychology perspective sociopolitical development as an antidote for oppression-theory and action sociopolitical development parent involvement, african american mothers, and the politics of educational care being a latinx adolescent under a trump presidency: analysis of latinx youth's reactions to immigration politics loss of institutional trust among racial and ethnic minority adolescents: a consequence of procedural injustice and a cause of life-span outcomes key: cord-266027-1xrq8cg9 authors: barrington, debbie s.; james, sherman a.; williams, david r. title: socioeconomic correlates of obesity in african-american and caribbean-black men and women date: 2020-07-04 journal: j racial ethn health disparities doi: 10.1007/s40615-020-00798-4 sha: doc_id: 266027 cord_uid: 1xrq8cg9 the high prevalence of obesity among black americans warrants additional investigation into its relationship with socioeconomic position (sep), sex, and ethnicity. this cross-sectional study utilizes 2001–2003 data from the national survey of american life, a nationally representative sample of 3570 african-americans and 1621 caribbean-blacks aged 18 years and older. multivariate logistic regression models stratified by ethnicity and sex describe the independent associations between obesity and multilevel socioeconomic factors after adjustment for age, other sep measures at the individual, family and neighborhood levels, and health behaviors such as physical activity, alcohol intake, and smoking. a positive relationship was observed between obesity and family income among african-american and caribbean-black men. receipt of public assistance was a strongly associated factor for obesity in caribbean-black men and women. among african-american women, inverse relationships were observed between obesity and education, occupation, and family income; residence within a neighborhood with a supermarket also decreased their odds of obesity. residence in a neighborhood with a park decreased the odds of obesity only among african-american men, whereas residence in a neighborhood with a supermarket decreased the odds of obesity among caribbean-black men. the social patterning of obesity by individual, household, and neighborhood socioeconomic resources differs for african-american and caribbean-black men and women within these cross-sectional analyses; an appreciation of these differences may be a prerequisite for developing effective weight control interventions and policies for these two populations. the high prevalence of obesity among non-hispanic black americans (38.3%), aged 18 years and older in 2018, as compared with 31.1% for the general us population, remains an important public health problem [1] . obesity has a broad range of health consequences, and its higher prevalence among non-hispanic blacks puts them at increased risk for type 2 diabetes (blacks = 13.0%, whites = 8.0%), coronary heart disease (black women = 5.2%, white women = 3.9%), asthma (blacks = 9.2%, whites = 8.0%), and stroke (blacks = 4.0%, whites = 2.7%) [1] . the important role of socioeconomic position (sep) in the obesity epidemic has long been a focus of research [2] [3] [4] [5] . sep is defined as one's location in the societal structure that determines differential access to power, privilege, and desirable resources [6] . it is a multidimensional concept that can be measured at (1) the individual level, e.g., education, earnings, and occupation; (2) the household level, characterized by familial resources, e.g., poverty, family income, and wealth; and (3) the neighborhood level, described by aspects of living conditions not captured by individual or household level variables, e.g., community structural characteristics, neighborhood poverty, and crime [7, 8] . prior research has documented correlations between lower rates of obesity and residence in communities with beneficial structural characteristics of neighborhood sep, including the presence of neighborhood parks and supermarkets [9] [10] [11] . research findings on the relationship between obesity and individual and household measures of sep, however, have been more mixed. for example, some studies have revealed a weakening of the protective effect of increasing education on obesity over the past 30 years, a consequence of the increase in obesity among the most educated [12] . the inverse association between sep and body mass index (bmi) and obesity is stronger among women compared with men [2, [13] [14] [15] [16] [17] . some studies, in fact, reported a reversal of the expected inverse sep-obesity association among men; i.e., men of high sep were more likely to have increased bmi and be overweight or obese than men of low sep [14] [15] [16] 18] . furthermore, nativity status (foreign-born vs. us-born) differentials in the association of an individual-level measure of sep on obesity have been reported among black americans, with native-born blacks being at higher risk [19] . few studies, however, have examined sex-specific associations between obesity and multilevel measures of sep within an ethnically diverse group of black americans. hence, the present study investigates the potential differential associations between obesity and individual, household, and neighborhood-level sep indicators among black american men and women (african-americans) and blacks with caribbean ethnicity (caribbean-blacks). elucidation of the differential patterning of multidimensional measures of sep on obesity among african-american and caribbean-black men and women would be beneficial for developing effective interventions to reduce obesity and obesity-related diseases within an increasingly heterogeneous us black population. this cross-sectional study utilizes data from the national survey of american life (nsal). the nsal is part of the national institute of mental health (nimh) collaborative psychiatric epidemiology surveys (cpes) initiative that also includes the national co-morbidity survey replication (ncs-r) and the national latino and asian american study (nlaas) [20] . nsal was conducted according to the guiding principles in the declaration of helsinki. all procedures involving human subjects, including oral and written consent from all participants 18 years of age and older, were approved by the institutional review board at the university of michigan [21] . the nsal includes a sample of 891 non-hispanic whites, 3570 african-americans, persons who identified as black but did not have ancestral ties to the caribbean (including 67 foreign-born blacks), and 1621 caribbean-blacks, persons who identified as black and who either were born in caribbean area countries (73% of the caribbean-black sample), had parents or grandparents who were born in the caribbean, or had indicated that they were of caribbean ethnicity. the nsal survey data includes assessments of mental, emotional, and physical health and residential, environmental, and socioeconomic characteristics. data were collected between february 2001 and june 2003 with response rates of 70.7% for african-americans, 77.7% for caribbean-blacks, and 72.3% for whites. this paper capitalizes on the growing heterogeneity of the us black population as reflected in the nsal sample and reports findings for african-american and caribbean-black men and women, aged 18 years and older within the nsal sample. the study outcome is obesity, characterized as having a body mass index (bmi, weight (kg)/height (m) 2 ) 30 or higher [22] . bmi is calculated within the nsal based on selfreported weight and height. the independent variables include self-reported measures of adult sep at the individual, family, and neighborhood levels. sep indicators at the individual level include current education specified as < high school (hs), hs and > hs, and respondent's main occupation categorized into professional/managerial, sales/administrative, skilled blue collar, unskilled blue collar, and service. sep measures at the family level consist of (1) a measure of wealth or "house value," specified as at or below the median, above the median, or "none," (2) quartiles of family income, and (3) "public support" described as currently receiving any public assistance for the family, and dichotomized into "any" or "none." finally, sep measures assessed at the neighborhood level include self-reported measures previously found to be associated with obesity within african-americans and caribbean-blacks-having a supermarket within one's neighborhood (yes vs. no) and having a park within one's neighborhood (yes vs. no) [23] . covariates utilized for statistical adjustment due to their known associations with sep and obesity include demographic variables such as age [5] , categorized into less than or equal to 29 years, 30-44 years, 45-59 years, and 60 or more years; marital status, [24] characterized as (1) married or living with a partner, (2) separated, divorced or widowed, and (3) never married; and three measures of health behaviors, (1) physical activity [22] , a continuous measure based on how often the study participants worked in the garden or yard, engaged in active sports or exercise, and walked, (2) smoking status [25] , specified as the participant never having smoked more than 100 cigarettes in his/her lifetime or "never smoker," having smoked more than 100 cigarettes in the past or "past smoker," and "current smoker," and (3) current alcohol consumption [22] , categorized for analytical purposes into consuming no alcoholic drinks within the past year or "none," having consumed less than 12 drinks within the past year, or "infrequent drinker," and moderate-to-heavy drinkers having consumed 12 or more drinks within the past year or "regular drinker." to minimize bias due to differentially distributed missing data on measures of sep and bmi by ethnicity (african-american and caribbean-black) and sex, multiple imputation was performed prior to statistical analysis within the statistical software package iveware [26] . iveware uses a sequential regression imputation method to impute values for each individual, conditional on all other values observed for that individual, consequently producing complete datasets for unbiased analyses [27] . descriptive statistics stratified by ethnicity and by sex were then calculated. chi-square tests were performed to examine group differences in categorical variables, whereas the global f test within an unadjusted linear regression model was utilized to calculate ethnicity and sex differences in physical activity. since previous studies reveal differential sep patterning of obesity by both sex and ethnicity [4, 19] , three-way interactions between measures of sep, ethnicity, and sex were tested. statistically significant three-way interactions were found for five out of the eight sep indicators, p values ranging from 0.008 to 0.024. therefore, all nested multivariate logistic regression models assessing the strength of the independent associations between multilevel measures of sep and obesity after covariate adjustment are presented stratified by ethnicity and sex. specifically, the following five models were fitted for each sep indicator: (1) odds ratios (ors) adjusted for age; (2) ors additionally adjusted for individual-level sep, i.e., education, occupation, as well as for marital status; (3) ors additionally adjusted for family-level sep, i.e., public support, house value, and family income; (4) ors additionally adjusted for neighborhood-level sep, i.e., neighborhood supermarket and neighborhood park; and (5) ors additionally adjusted for health behaviors, i.e., physical activity, alcohol intake, and smoking. data management was conducted using sas version 9, [28] and all statistical analyses were performed using sudaan [29] to account for the multiple imputation and the complex sample design of the nsal in calculating unbiased effect estimates and standard errors. sample sizes presented within tables are un-weighted; however, all other estimates, means proportions, and standard errors, as well as ors and 95% confidence intervals (cis), are weighted. table 1 describes the general characteristics of african-american and caribbean-black men and women in the nsal sample. african-american women had the highest prevalence of obesity at 41.2% followed by caribbean-black women at 31.1% and african-american men at 29.9%. caribbean-black men had the lowest prevalence of obesity at 21.6%. caribbean-black men and women were also younger than african-american men and women with 64.9% and 66.2% of caribbean-black men and women being under the age of 45 as compared with 61.0% and 58.8% of african-american men and women, respectively. caribbean-black men and women had greater educational attainment than african-american men and women, with 49.4% of caribbean-black men and 48.8% of caribbean-black women and 37.3% of african-american men and 38.4% of african-american women having > hs education. men were more likely to be married or living with a partner than women; caribbean-black men had the highest prevalence at 59.9%, while african-american women had the lowest at 35.6%. in addition, men were more likely than women to be employed in the skilled and unskilled blue collar professions; unskilled blue collar employment was highest for african-american men at 33.2%. women were more likely than men to be employed in service professions. moreover, caribbean-black men and women, at 23.0% and 23.3%, respectively, were more likely to work in professional/ managerial positions compared with african-american men and women at 15.4% and 17.9%, respectively. african-american women were the most likely to receive public support, and accordingly, most likely to have had the lowest family income compared with all other ethnic/sex groups. caribbean-black men were least likely to receive public support and to have had the highest family income. african-american men were most likely to be homeowners relative to all other ethnic/sex groups, whereas caribbean-black women were least likely to be homeowners. caribbean-black men and women were more likely than african-american men and women to live in neighborhoods that had a supermarket or a park. caribbean-black men had the highest prevalence, in that 91% lived in a neighborhood with a supermarket and 88.1% resided in a neighborhood with a park. african-american women had the lowest prevalence with approximately 71% residing in a neighborhood that had a supermarket or park. men reported higher rates of physical activity than women, with caribbean-black men having the highest average score (2.95) and african-american women having the lowest (2.56). seventy-nine percent of caribbean-black women never smoked, whereas only 49.4% of african-american men never smoked. finally, african-american women were least likely to consume alcohol in the past year where 43.5% never drank. caribbean-black men were most likely to drink alcohol in the past year and 55.7% were regular drinkers. tables 2, 3, 4, and 5 present the adjusted odds ratios (ors) and 95% confidence intervals for the associations between obesity and individual-, family-, and neighborhood-level socioeconomic position (sep) among african-american men, caribbean-black men, african-american women, and caribbean-black women, respectively. unless otherwise stated, all ors were determined from the fully adjusted models. for african-american men, no significant associations between obesity and any individual-level measure of sep were observed ( table 2) . low sep at the family level, however, was associated with a lower odds of obesity. within all adjusted models for african-american men, family income within the lowest quartile was protective against obesity relative to the highest quartile, or = 0.50, 95% ci (0.27, 0.92). furthermore, african-american male homeowners with housing equity at or below the median had a 43% increased odds of obesity compared with their non-home-owning counterparts, or = 1.43, 95% ci (1.00, 2.06). neighborhood-level sep was also associated with obesity, with all adjusted models showing lower odds of obesity for african-american men residing in neighborhoods that contained a park compared with those who lived in neighborhoods without one (or = 0.60, 95% ci (0.38, 0.94)). as shown in table 3 , none of the individual-level measures of sep for caribbean-black men was significantly associated with obesity, paralleling the findings for african-american men. nevertheless, selected family-and neighborhood-level sep measures were associated with obesity. for example, like african-american men, low family income was protective for caribbean-black men within the age-adjusted model; however, this association became non-significant (p > 0.05) with additional covariate adjustment. furthermore, caribbean-black men who received any public assistance had 3.5 times the odds (95% ci 1. 30, 9.42) of obesity compared with their counterparts who did not. finally, caribbean-black men residing in a neighborhood containing a supermarket experienced an 86% decreased odds of obesity compared with those in neighborhoods without this amenity, or = 0.14, 95% ci (0.04, 0.52). in contrast to men, table 4 shows statistically significant associations between measures of individual-level sep and obesity for african-american women. african-american women with < hs education had 1.47 times the odds (95% ci (1.04, 2.09)) of obesity than those with > hs education. though only borderline significant in fully adjusted models, african-american women with a hs education had 1.40 times the odds (95% ci (0.96, 2.05)) of obesity compared with those with > hs education. african-american women employed in the sales/administrative occupations had 27% lower odds of obesity compared with african-american women employed in service employment, or = 0.73, 95% ci (0.57, 0.94). in contrast to african-american men, higher family sep was protective against obesity for african-american women. though of borderline significance, african-american women who received public support had a 27% greater odds of obesity compared with those not receiving such support, or = 1.27, 95% ci (0.98, 1.63). though not statistically significant, african-american women with family income in the third quartile were associated with a 35% increased odds of obesity compared with women in the highest quartile, or = 1.35, 95% ci (0.97, 1.89). african-american females with housing table 5 summarizes associations between sep and obesity among caribbean-black women. occupation is the only individual-level sep measure that was associated with obesity in this group. being employed within professional/managerial occupations was associated with a decreased odds of obesity compared with employment in service occupations, after adjusting for age, marital status, and other individual-level, family-level, and neighborhood-level sep measures, or = 0.55, 95% ci (0.30, 0.99). this association became statistically insignificant, however, after adjusting for physical activity, smoking, and alcohol consumption, or = 0.61, 95% ci (0.35, 1.07). similar to african-american women, receipt of public assistance increased the odds of obesity for caribbean-black women; however, the magnitude of the association was stronger for the latter. caribbean-black women receiving public support had 1.74 times the odds of obesity compared with caribbean-black women not on public assistance, 95% ci (1.08, 2.82). yet, unlike african-american women, in ageadjusted and individual-level sep adjusted models, caribbean-black women with family income in the third quartile had a decreased odds of obesity compared with those with family income in the fourth quartile. in fully adjusted models, this relationship became statistically insignificant, or = 0.56, 95% ci (0.28, 1.14). no association was observed between this study of the association between multiple dimensions of sep (individual, family, and neighborhood) and obesity in a sample of us blacks found that associations varied by ethnicity and by sex. among african-american men, no statistically significant associations between sep and obesity were observed at the individual level, but a positive relationship was observed for family sep; namely, african-american men in the bottom quartile of family income and who had no housing equity had the lowest odds of obesity. similar to african-american men, there was no association between adulthood sep at the individual level among caribbean-black men. for caribbean-black men, more complex sep patterns for family income were observed, wherein (1) obesity increased among those receiving public assistance and (2), similar to african-american men, a positive association was observed between family income and obesity. the association between public assistance and the increasing odds of obesity among caribbean-black men is consistent with a previous report showing that participation in public assistance programs increased the risk of adult obesity [30] . in this particular study, the association was stronger among men than women and was mediated by dietary quality as assessed by higher soda consumption. moreover, in the current study, our finding of a positive association between obesity and sep at the family level among black men is also in line with previous reports [5, 14, 31, 32] . african-american elementary school boys with low sep have been reported to engage in more vigorous physical activity than high sep boys through participation in team sports such as football and basketball [33] . this engagement in vigorous team sports, if it [34] , is a possible contributing factor in lowering the risk of obesity among low sep african-american and caribbean-black men. this is a hypothesis that should be tested in prospective research. moreover, the higher obesity rate among high sep men has been postulated to be due to the positive effect increased body weight has on higher earned income and social prestige among men [35] . future longitudinal investigations should determine whether perceived and actual positive economic consequences for increasing body size drive the positive relationship between sep and obesity among men. for african-american women, the expected inverse relationship between individual-level sep and obesity was seen for education [15] ; however, educational attainment was not associated with obesity among caribbean-black women. in line with previous research [36] , our study also reveals that higher status occupations, i.e., sales and administrative jobs among african-american women and professional and managerial jobs among caribbean-black women, are associated with lower odds for obesity than lesser status service professions. finally, our results at family-level sep show that similar to caribbean-black men, receipt of public assistance increased odds for obesity among women, with a stronger association for caribbean-black women. lastly, our results show important ethnic and sex differences in the association between community sep characteristics and obesity. the lower odds of obesity among caribbean-black male and african-american female residents in neighborhoods containing a supermarket is consistent with prior research [23, 37] . in addition, the lower odds of obesity for residence within a neighborhood containing a supermarket found among caribbean-black women suggests that this relationship may hold for them as well despite the lack of statistical significance most likely due to low statistical power. the absence of any relationship between obesity and residence within a neighborhood containing a supermarket among african-american men warrants further investigation. it is important to highlight the substantial decrease in the odds of obesity exclusively among african-american men who live in neighborhoods containing a park. research has shown that increased access to parks is associated with increased moderate-to-vigorous physical activity in boys but not among girls aged 8 to 12 years [38] . for many black men, these childhood patterns of engaging in vigorous competitive team sports (e.g., basketball) in neighborhood parks extend into early adulthood, a pattern not seen historically among black women [39, 40] . additional research is needed to determine whether elevated energy expenditure due to increased access to recreational parks across the life course explains the lower prevalence of obesity among african-american men living in neighborhoods with community parks. previous research documenting a lack of association between sep and exercise frequency in black women may explain the absence of a relationship between neighborhood parks and obesity among african-american and caribbean women within our findings [41] . further theoretical and empirical investigations are needed to uncover additional mechanisms through which measures of sep at the neighborhood level independently operate to increase obesity within the various ethnic and sex groups. to our knowledge, this is the first study to document associations between multilevel and multidimensional measures of sep and obesity in a sample of us self-identified and caribbean self-identified black americans, while using an intersectionality approach centered on both within-race ethnic and sex differentiation. methodological strengths also include the employment of multiple imputation of missing data. this study has several limitations, however. multiple imputation was not performed on measures with over 40% of missing data, such as individual-level income, and so, this variable was not included within the analysis in order to minimize bias [42, 43] . furthermore, the lower sample size of caribbean-blacks within the nsal dataset limited statistical power to examine any additional variation in the sep-obesity associations by nativity status, i.e., foreign-born vs. us-born. the public-use nsal questionnaire utilized for analysis included only self-reported measures of neighborhood physical characteristics and did not allow for geocoding addresses to include census tract measures, i.e., percentages of families below the poverty, unemployed and/or low-educated adults, and homeowners within a neighborhood, for multilevel modeling. although the inability to examine objective assessments of neighborhood sep within hierarchical models is a disadvantage, perceived measures of neighborhood resources have been found in previous studies to be equally robust correlates of obesity as observed neighborhood indicators [44] . the cross-sectional nature of the nsal study design does not establish a clear, unbiased temporal relationship between multilevel sep indicators and adult obesity; therefore, neither causality nor direction of the sep-obesity associations can be ascertained with certainty. the nsal, one of the few studies that allow for an examination of the socioeconomic correlates of cardio-metabolic health by ethnicity and sex within black americans, was conducted in 2001-2003 and hence is an established dataset. notwithstanding, the stability of sep indicators over time for black americans, including median income, which was $40,573 in 2003 and $41, 361 in 2018, supports the present-day relevancy of our findings [45] . the use of self-reported weight and height to estimate obesity prevalence is also a potential bias. studies have found that these self-reported measures are reasonably valid and reliable indicators of actual weight and height, although obese individuals tend to underestimate their weight [46] [47] [48] . a dilution rather than an exaggeration of the magnitude of our associations is expected however if a systematic underreporting of weight is similar across sep categories. statistical adjustment for additional health behaviors related to obesity such as dietary quality could not be made within the analyses since this information is not assessed in the nsal. in addition, physical activity, crudely assessed within the nsal as a continuous measure of reported leisure time activity, is a less reliable measure of activity level than other methods which directly monitor the intensity of physical activity such as the use of double isotopically labeled water (d 2 o 18 ) methodology and measurement by a pedometer or tachometer [49] . the extent to which the inclusion of dietary intake and a more reliable indicator of the intensity of physical activity would explain the associations between multilevel indicators of sep and obesity cannot be determined. our study findings highlight that adulthood sep at the individual, family, and neighborhood levels plays an important role in obesity in the us black population, and this varies by ethnicity and sex. the opposite sep-obesity relationships between black men and women suggest the need for further empirical investigation into the sex-specific mechanisms of obesity, particularly among low sep families where the disparity between young adult black women and men is the largest [50] . moreover, the lower odds of obesity associated with residence in neighborhoods with a supermarket for african-american women and caribbean-black men, and with residence in neighborhoods containing a park for african-american men, suggests that continued public policy attention to increasing access to food and recreational facilities within black american communities, as was undertaken in the national "let us move!" comprehensive initiative for preventing childhood obesity [51] , is likely to be an important endeavor. evidence from this study also suggests that the development of targeted, multilevel, cultural, and sex-specific societal interventions could be vital to not only curtailing the us obesity epidemic but to reducing racial inequities in survival from emerging infectious diseases such as covid-19, for which obesity has arisen as a strong risk and prognostic factor in its severity [52] [53] [54] . funding information this study was funded by the robert wood johnson health and society scholar's program and by the national institute on minority health and health disparities (grant number k22md006133). conflict of interest the authors declare that they have no conflicts of interest. ethical approval all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. informed consent informed consent was obtained from all individual participants included in the study. tables of summary health statistics for socioeconomic status and obesity: a review of the literature socioeconomic status and obesity socioeconomic status and obesity the obesity epidemic in the united statesgender, age, socioeconomic, racial/ethnic, and geographic characteristics: a systematic review and meta-regression analysis socioeconomic position in social epidemiology measuring social class in us public health research: concepts, 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american young adults: contributions of sociodemographic characteristics of the childhood family white house task force on childhood obesity report to the president. solving the problem of childhood obesity within a generation patients in a large health care system in california covid-19 is out of proportion in african americans obesity as a predictor for a poor prognosis of covid-19: a systematic review publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-346603-ooaur990 authors: luterbacher, j.; newfield, t. p.; xoplaki, e.; nowatzki, e.; luther, n.; zhang, m.; khelifi, n. title: past pandemics and climate variability across the mediterranean date: 2020-09-19 journal: euromediterr j environ integr doi: 10.1007/s41207-020-00197-5 sha: doc_id: 346603 cord_uid: ooaur990 the influence that meteorological, climatological and environmental factors had on historical disease outbreaks is often speculated upon, but little investigated. here, we explore potential associations between pandemic disease and climate over the last 2,500 years in mediterranean history, focusing on ancient disease outbreaks and the justinianic plague in particular. we underscore variation in the quality, quantity and interpretation of written evidence and proxy information from natural archives, the comlexity of identifying and disentangling past climatological and environmental drivers, and the need to integrate diverse methodologies to discern past climate-disease linkages and leverage historical experiences to prepare for the rapid expansion of novel pathogenic diseases. although the difficulties entailed in establishing historical climate-pandemic linkages persist to the present, this is a research area as urgent as it is complex and historical perspectives are desperately needed. the dynamics of the ongoing covid-19 pandemic are an urgent research area of great importance to governments across the mediterranean. decisions of significant public health and economic consequence are influenced by epidemiological forecasts and spread-modifying factors associated with the physical environment (covid-19 e-symposium outcome statement, 2020). meteorological, climatological and environmental factors may influence sars-cov-2 transmission and may have contributed to its emergence, though current evidence is not yet consistent or conclusive (covid-19 e-symposium outcome statement, 2020). although the interdisciplinary research required to untangle complex relationships between climate and disease outbreaks could benefit from historical perspectives, available data on past climate-disease linkages are of shallow come. here we begin to explore pandemic disease's associations with climate and environmental changes in mediterranean history. we underscore variation in the quality, quantity and interpretation of written evidence, the complexity of identifying and disentangling past climatological and environmental drivers, and the need to integrate diverse methodologies if we are to leverage historical experiences to prepare for the rapid expansion of novel pathogenic diseases. roughly 2450 years before sars-cov-2 made its appearance in the mediterranean region, thucydides (1956 ii.47-54) authored an account of a plague that had commenced, he claimed, in east africa before spreading in the eastern mediterranean and devastating his home polis. cryptic references to sumerian, hittite and biblical disease outbreaks aside, many historians consider this athenian plague, 430-27 bce, among the first interregional disease outbreaks, pandemics, to affect the mediterranean. the antonine, cyprianic, and justinianic, plagues (morgan 1994; gilliam 1961 gilliam , 1996 greenberg 2003; harper 2015; sarris 2002; mordechai et al. 2019) followed. eight centuries then passed before the black death, 1346-53 ce, the greatest pandemic in recorded world history, quickly killed tens of millions of people across the mediterranean and far beyond (biraben 1975; benedictow 2004; green 2014) . like the justinianic plague, the black death marked the arrival in the region of yersinia pestis, the cause of bubonic, pneumonic and other varieties of plague. for more than two centuries following the 6th-century pandemic, and five following the 14th-century pandemic, y. pestis would repeatedly reemerge within the mediterranean region and europe, often claiming vast numbers of lives, as in egypt 1429-30 ce, spain 1596-1602 ce and italy 1629-31 ce (biraben 1975; stathakopoulos 2004; borsch 2005; alfani 2017; mackay 2019; varlik 2014) . that our current understanding of these outbreaks is, like the foregoing sketch of mediterranean disease outbreaks, enormously incomplete, considerably complicates attempts to establish connections between them and climate. the chronology and geography of the earliest plagues are poorly understood, so too their pathogenic identity. most diagnoses of prelaboratory plagues are debated, with the exception of those of the justinianic plague and black death, for which we now have confident dna-based y. pestis identifications (bos et al. 2011; spyrou et al. 2019; keller et al. 2019a, b) . that the earliest of the aforementioned plagues were the most demographically or socioeconomically significant ones to afflict the ancient mediterranean is itself uncertain. some doubt whether the antonine plague was a pandemic at all and the construction of the cyprianic plague begs for closer scrutiny. for all we know, other outbreaks, more poorly documented yet, like the "deadly epidemic" of 65 ce, which purportedly killed 30,000 in rome in a single autumn alone and left "houses filled with lifeless bodies and streets with funerals" (tacitus 1962 xvi.13; suetonius nero 1914 xxxix.1) , could have been more disruptive. between the last known justinianic recurrence and the black death (~ 750-1345 ce), other disease outbreaks, possibly significant but hitherto ignored, occurred too (schnerrer 1823; curschmann 1900). there is much to do in mediterranean disease history. whether the aforementioned plagues represent novel disease emergences or the introduction of a disease endemic elsewhere is important. unsurprisingly, our understanding of historical pandemic origins remains poor. the antonine plague may have emerged in north africa or southwest asia, and the cyprianic plague in east africa or the pontic steppe; alternatively, these regions may simply be where these plagues entered the purview of literate observers. the alleged east african origins of many ancient plagues (gilliam 1961 (gilliam , 1996 harper 2015; allen 1979 ) may owe little more than to greco-roman prejudices and thucydides' influence, but few mediterranean plagues may have been limited to the mediterranean region itself; some, like the justinianic plague and black death, were more global in scope. a number of scholars have attempted to untangle past climate-plague relationships (stothers 1999; rossignol and durost 2007; schmid et al. 2015; elliott 2016; campbell 2017; green 2018; newfield 2018a) . to establish whether climatological and environmental factors influenced the emergence of past mediterranean pandemics knowing where and when the outbreak began, and its pathogenic identity, are fundamental, as are high quality, long-running climate records from different archives, which resolve various aspects of climate and environment change at high spatial and temporal resolution and which also cover the full annual cycle. although the mediterranean region offers an unusually rich combination of natural archives (terrestrial and marine proxies, including tree-rings, speleothems, lake, river and marine sediments, and vermetids), as well as comparatively plentiful, albeit spatiotemporally variable and highly heterogeneous, documentary evidence ( fig. 1; bradley 2015; luterbacher et al. 2012; finné et al. 2019; labuhn et al. 2018; xoplaki et al. 2018 ), records extending back to antiquity remain limited. not only is knowledge of mediterranean climate during the aforementioned plagues remarkably incomplete, but also high-resolution climate proxies, which are required to discern potential climate-disease linkages, are particularly scarce. coverage for different seasons and variables (temperature, precipitation, drought, sea level changes, ph, sea water temperature, water mass circulation, etc.) are also uneven. figure 2 plots the range of climate evidence from various proxy records available for the central and eastern mediterranean region and covering the past one-to-two millennia (luterbacher et al. 2021, in press ). as tricky as establishing climate-pandemic correlations may be, teasing out causal linkages is far more difficult. climate and disease interact in complex ways and simultaneously through cultural and environmental systems as well as social and economic structures. the effects of climate change on pandemics will vary accordingly between and within regions and evolve as an outbreak persists, from emergence to cessation. concern for temporal and spatial scales, of climate and disease, is consequently vital and broad-stroke sketches of historical linkages (keys 1999; mcmichael 2011; harper 2017) , particularly for past pandemics for which evidence is still partial, are certain to mislead. while causal mechanics are instead to be discerned in more small-scale analyses (stenseth et al. 2006; ben ari et al. 2011; haldon 2016) , that climate and disease will have interacted historically at various points, and on various temporal and spatial scales, within one outbreak remains a major research challenge. climate may shape the course of a disease outbreak indirectly via its influence on vegetation and agroecosystems, and, for instance, on the cascading effects stemming from failed harvests, such as migration for food and work, malnutrition and compromised immune function. it can concurrently intersect with disease ecology and transmission, affecting host and vector populations and human behaviour in ways that alter pathogen dissemination and disease severity. usually cool conditions might cause more people to spend more time indoors, which in crowded habilitations could facilitate the dissemination of respiratory pathogens and diseases hosted by commensal rodents or arthropods (neher et al. 2020) . without an understanding of these factors, causal climate-disease mechanisms will remain challenging to establish. we must also stay cognizant of the influence of climate variability on endemic infectious disease in regions in which an outbreak spreads, as alterations to preexisting disease landscapes would affect outbreak outcomes. the same rainfall-temperature variation that facilitates a plague spillover in a given region (stenseth et al. 2006; ben ari et al. 2011 ) might also, for instance, meaningfully diminish populations of anopheles mosquitoes which spread malaria and consequently limit malaria-plague coinfections (newfield 2017) . untangling historical pandemic-climate linkages is plainly no easy task. consider that the four earliest aforementioned plagues each temporally correspond to some of the largest climate-forcing volcanic eruptions of the last 2500 years (fig. 3) . tempting as it may be to link these plagues to these eruptions, correlation and causality by no means necessarily go hand-and-hand. while the athenian, antonine, cyprianic and justinianic plagues each correlate to an unusually large, climate-forcing eruption, we do not yet possess the data and understanding of these events we need to connect them. the unidentified eruptions of ~ 426 bce, ~ 160 ce and ~ 169 ce, and ~ 266 ce, like the eruptions of 536 ce and 540 ce (büntgen et al. 2016; newfield 2018b) , clearly impacted northern hemispheric tree-ring based reconstructed summer temperatures. however, whether such seasonally-based temperature variability facilitated the emergence or diffusion of these outbreaks is, without definitive diagnoses and a clear grasp of spatiotemporal parameters, unclear. there was, evidently, no simple relationship between summer cooling and ancient mediterranean pandemic disease, as several pronounced cooling periods do not correspond to known large-scale disease outbreaks, including the cooling associated with the massive eruption of 43 bce (mcconnell et al. 2020 ). weary as we should be of drawing macro-level climate-pandemic linkages on the basis of current evidence, that significant summer cooling contributed to pandemic emergence beyond the mediterranean region, whether in africa, asia or europe, and facilitated mediterranean disease diffusion, indirectly through a combination of mechanisms, remains a possibility, as plague-cooling concurrences visualised in fig. 3 may suggest. yet, for all we presently know, significant summer cooling, volcanically forced or not, may have actually served to limit the spread of rodent-borne or arthropod-vectored pandemics (newfield 2018a, b) . major volcanic events and corresponding summer cooling do seem to occur at the tail end of both the athenian and cyprianic plagues. at the same time, the diagnoses and epidemiology of those plagues are to be determined and whether that cooling occurred on a local scale in plagueaffected regions, like athens, is entirely unclear without sufficiently long-running mediterranean climate proxies that resolve intraannual variability. of ancient pandemics, we know most about the justinianic plague, though uncertainties still complicate potential climate and environmental linkages. remnants of y. pestis have been identified in the remains of ~ 45 late antique individuals (wiechmann and grupe 2005; harbeck et al. 2013; wagner et al. 2014; feldman et al. 2016; keller et al. 2019a, b) , confirming the symptom-based plague diagnosis of this pandemic. but the origins of the outbreak are murky. most historians, following the 6th-century authority procopius (1914 ii.22-23) , hold the pandemic enters recorded history in july 541 at pelusium in the eastern nile delta, though other late antique sources suggest the disease appeared first in southern southwest asia or east africa. the phylogeny of ten plague genomes reconstructed from late antique human plague victims (harbeck et al. 2013; wagner et al. 2014; feldman et al. 2016; keller et al. 2019a, b) indicate that the justinianic plague y. pestis lineage originated centuries earlier in central asia (possibly in the foothills of the tian shan mountains in modern-day kyrgyzstan). in the emergence-pandemic interval, it has been hypothesized that y. pestis focalised in east africa (green 2015; cf. keys 1999) and irrupted as the justinianic plague in that region not long before 541 ce and that it then either travelled north to the red sea port of berenice, before transferring to the nile and heading north, or to the port of clysma, before entering the eastern delta via the amnis traianus, an ancient canal connecting the red sea and eastern nile delta (stathakopoulos 2004; mccormick 2007; tsiamis et al. 2009 ). whichever route, these theories take for certain procopius' identification of pelusium as the mediterranean city first hit and the thucydidean claim of evagrius (2000 iv.29 ), a late 6thcentury historian, that the plague began in east africa. john of ephesus, who like procopius lived through the justinianic plague, discusses the pandemic first in alexandria, but identifies populations south of egypt and in southern arabia (former himyarite and kush lands) as struck early on (michael the syrian 1901 ix.28). later texts write of the plague spreading through the eastern mediterranean as well as east africa and persia, but do not specify which region was struck initially (newfield 2018a). as stressed, disease ecology and epidemiology are fundamental to establish climate-pandemic linkages. plague is a complex disease (dubyanskiy and yeszhanov 2016; jones et al. 2019) . over 200 species of rodents and 30 species of fleas are known to maintain y. pestis today in tens of foci in more than 25 countries on four continents (baril et al. 2019) . far from all current foci are centuries-old and many are doubtless extinct. the justinianic plague may have emerged from a non-extant reservoir in east africa or southern arabia, where sixth-century writers identify the disease first, or farther afield yet, but small genetic variations in the ten late antique plague genomes presently available teach that recorded justinianic plague recurrences in the mediterranean region represent not y. pestis reintroductions from afar, but re-emergences from one or more historical plague reservoirs in the mediterranean region (keller et al. 2019a; tsiamis et al. 2011) . historians of the black death have speculated that marmots in the southern alps, jerboas in anatolia and voles in england maintained second-pandemic plague (carmichael 2014; varlik 2014; pribyl 2017) , but what rodents might have hosted first-pandemic plague in the mediterranean region remains uncertain. it has been emphasized that for plague to persist and cause human spillovers for centuries a plurality of rodents and fleas, sylvatic and commensal (dubyanskiy and yeszhanov 2016; jones et al. 2019) , would have been involved in any given region. that small ruminants and camels can maintain the disease as well could be another important factor (malek et al. 2016; dai et al. 2018) . while repeated reemergences from regional rodent reservoirs may have been associated with climate, not knowing where plague focalised or what species were involved complicates attempts to discern a consistent 'signal', such as an unusually wet-humid growing fig. 4 tree-based reconstruction of european summer temperature anomalies (w.r.t. 1961 -1990 luterbacher et al. 2016) ; tree-based reconstruction of central european summer precipitation using the palmer drought severity index (cook et al. 2015) ; speleothem-based mg/ca record indicative of autumn winter precipitation from closani, southwestern romania (warken et al. 2018 ); speleothem-based δ 13 o record partially indicative of hydroclimate from uzuntarla, northwestern turkey (göktürk 2011) ; varved sediment-based record of δ 18 o indicative of winter-spring precipitation from lake nar, central turkey (jones et al. 2006 ); speleothembased record of δ 13 c indicative of hydroclimate from jeita, lebanon (cheng et al. 2015) ; estimated global stratospheric aerosol optical depth (aod) of large volcanic eruptions derived from polar ice-core sulfate records (toohey and sigl 2017) . yellow-hatched bars represent the justinianic plague (541-544 ce) and record first plague pandemic recurrences. this plague chronology follows stathakopoulos (2004) , but the written record of late antique plague presents many challenges and other chronologies differ slightly (tsiamis et al. 2011; harper 2017) season on the heels of a drought (ben ari et al. 2011) , in available paleoclimate proxies. that the written record of late antique plagues is incomplete, the full spatiotemporal scope of every first-pandemic plague outbreak is unknown, and the chronology and scope of identifiable individual outbreaks is debated, are major additional confounding factors. further, not every reemergence needs to have been climate triggered, nor need every climate-trigger spillover have spread widely. as visualized in fig. 4 , any simple correlation between plague reemergence and european summer temperatures (luterbacher et al. 2016) or continental european summer precipitation is unapparent (cook et al. 2015) . several selected regional proxies (see fig. 2 for locations) similarly do not align tidily with the written record of first-pandemic plague recurrences, such as speleothem-based reconstructions of autumn-winter precipitation from closani, southwestern romania (warken et al. 2018) , of hydroclimate from uzuntarla, northwestern turkey (göktürk 2011) , or of the hydroclimate from jeita, cental lebanon (cheng et al. 2015) . likewise, a sediment-based record of winter-spring precipitation from lake nar, central turkey, does not correlate with known plague recurrences (jones et al. 2006) . the uzuntarla and nar records, which are subdecadally resolved but not annually, and the jeita record, which is of lower resolution yet, makes obvious the importance of high spatio-temporal resolved proxies that also cover seasonal climate aspects. identifying plague-climate linkages using a climate record dated at five-year intervals is understandably challenging. the largest late antique volcanic eruptions, and their associated forcing on northern hemispheric climate, each correspond to a plague outbreak, but the majority of outbreaks are associated neither with large eruptions nor summer cooling in europe. whether a pronounced multi-year megadrought archived in some speleothem and lake records from southern arabia and northern ethiopia 10-to-20 years before the appearance of the justinianic plague in late antique texts (fleitmann et al. 2007; marshall et al. 2009 ) is relevant to the onset of the first plague pandemic is unclear, but is worth exploring further considering aforementioned arguments for a proximate origin of the justinianic plague in either region. a more concerted effort has been made recently to understand the black death in the context of climate change (schmid et al. 2015; campbell 2016; green 2018) . the focus has set again on the pandemic's origins, which phylogenetic analyses of y. pestis isolated from late medieval and early modern plague victims have come to inform. the pandemic reached the mediterranean in late summer 1347 (byzantine lands in august-september, sicily in october, and egypt and southern france in november) from the black sea and likely through southwest asia, having spread in the il-khanate in the 1340s and reached baghdad in summer 1347 (benedictow 2004; barker 2021, forthcoming) . the outbreaks's earlier geography is tough to establish, but it has been located next to lake issyk kul in kyrgyzstan in 1338 and in far-removed azerbaijan, crimea and uzbekistan in 1346 (benedictow 2004; green 2018; slavin 2019; barker 2021) . the date of the black death's initial spillover is widely speculated. the emergence of the pandemic's y. pestis lineage is dated presently to ~ 1250 ce (cui et al. 2013; spyrou et al. 2019) , and while some argue the pandemic commenced only ~ 10 years before it reached the purview of western eurasian observers, others have proposed, recently and long ago, that plague spread earlier in east and central asia, as early as the mid-thirteenth century (hecker 1832; hymes 2014; green 2014) . plague genomes also indicate that plague focalized in or near the mediterranean region and europe following the black death and reemerged regionally for centuries (bos et al. 2016; seifert et al. 2016; spyrou et al. 2016 spyrou et al. , 2019 namouchi et al. 2018) , doing away with the epidemiological orientalism that informed earlier claims of repeated mediterranean reintroductions from afar. yet, whether climate influenced initial emergence or subsequent mediterranean-area spillovers remains an open question, as where and when precisely second-pandemic plague emerged, and the locations and species composition of any mediterranean or european reservoirs, are uncertain. connections hitherto drawn between the black death and the large, climate-forcing eruption of samalas, indonesia (1257; guillet et al. 2017) or the early fourteenth-century european pluvial (cook et al. 2015) , are not robust. finer dating and mapping of the pandemic's emergence and closer attention to associated sylvatic rodent ecology in connection to perceptible climate change are much needed. regarding mediterranean-region re-emergences, different foci with particular environmental and climate ties could have sourced outbreaks in any one region. some reservoirs may not have lasted long. how meteorological, climatological and environmental variables shaped outbreaks post emergence is likewise an intricate issue, as mechanisms of second-(and first-) pandemic plague transmission could have varied spatially and temporally. outbreaks could, for instance, involve commensal, semi-commensal and slyvatic rodents and their fleas, as well as, or perhaps only, human fleas and lice. plague could as well spread pneumonically and gastrointestinally. clearly, the obstacles we have yet to overcome with regard to climate's possible influence on the justinianic plague and the first plague pandemic likewise complicate our understanding of potential black death and second plague pandemic associations with climate. we are confronted with similar challenges today. the original and intermediate host species of sars-cov-2 are uncertain (the horseshoe bat and a pangolin species are, respectively, probable), as are where and when the intermediate host acquired the virus and sars-cov-2 jumped to humans (anderson et al. 2020; liu et al. 2020; xiao et al. 2020) . sequence data from early samples suggests the novel coronavirus spilled over into people in mid-to-late november 2019 (anderson et al. 2020; dorp et al. 2020; li et al. 2020) , possibly weeks before the first identified case (huang et al. 2020 ), but earlier unconfirmed cases confound the issue. with such a fragmentary grasp of key events, whether changing weather patterns facilitated the emergence of sars-cov-2 is imperceptible. the difficulties entailed in establishing historical climatepandemic linkages, of course, are far greater. nevertheless, this is a research area as urgent as it is complex. historical perspectives are desperately needed. poor data availability and spatiotemporal resolution represent major challenges we must overcome. gathering existing data and producing what are still needed to identify causal mechanics connecting weather, climate and environmental conditions to disease will take time, but has the potential to improve significantly not only our grasp of historical spillovers but also how meteorological, climatological and environmental changes contributes to the dissemination of known infectious diseases and the development of new ones. interdisciplinary collaborations will be pivotal moving forward, so too case studies focused on periods, places and disease outbreaks for which high-resolution data and definitive or near-definitive diagnoses are obtainable. importantly, case studies of major historical disease outbreaks, like those addressed here, may prove informative, but concentrating on recent historical periods may yield, for the reasons we have stressed, fuller climate-disease histories. still, working across disciplines we can begin to reliably reconstruct climate's influence on past disease and leverage that knowledge for epidemic preparedness and spillover risk assessments today. funding open access funding provided by projekt deal. open access this article is licensed under a creative commons attribution 4.0 international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/. plague in seventeenth-century europe and the decline of italy: an epidemiological hypothesis the justinianic plague the proximal origin of 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castelan, andrea; sagong, chaewon; casement, melynda d.; drake, christopher l. title: racial discrimination as a mediator of racial disparities in insomnia disorder date: 2020-09-11 journal: sleep health doi: 10.1016/j.sleh.2020.07.007 sha: doc_id: 349664 cord_uid: p5j26lvd study objectives: racial and ethnic minorities are more likely to suffer from insomnia that is more severe; however, few studies have examined mechanisms by which racial disparities in severity of insomnia disorder may arise. one potential mechanism for disparities in insomnia severity is perceived discrimination. this study tested discrimination as a mediator in the relationship between race and insomnia. methods: participants were recruited from communities in the detroit metropolitan area and were diagnosed with insomnia disorder using the dsm-5 (diagnostic and statistical manual of mental disorders, fifth edition). the final sample included 1,458 individuals. insomnia symptom severity was assessed via the insomnia severity index and self-reported racial discrimination was evaluated using a single item. racial discrimination was tested as a mediator in the relationship between race and insomnia symptom severity. individuals were categroized as either white or a racial minority (i.e., non white individuals), with sensitivity analyses examining black individuals and non-black racial minority groups. results: consistent with our hypothesis, racial discrimination was a significant mediator accounting for 57.3% of the relationship between race and insomnia symptom severity. sensitivity analyses indicated that the indirect effect of racial discrimination was stronger in the non-black racial minority group compared to black individuals. conclusions: these results provide support that racial discrimination is likely an important mechanism by which racial and ethnic sleep disparities exist. implications for prevention, intervention, and treatment of insomnia in racial minorities to reduce health disparities are discussed. among several of the fundamental and longstanding societal challenges we face is the problem of racial disparities in health. an overwhelming body of evidence indicates that living as a racial minority in the united states is frequently accompanied by excessive rates of chronic disease (e.g., hypertension, diabetes, and obesity) 1 and disproportionate mortality across the most prevalent diseases. 2à4 unsurprisingly, racial sleep disparities also exist. a multitude of evidence indicates that racial minority groups are more likely to report sleep disturbances compared to white individuals. 5à10 for example, black individuals report having worse sleep quality, 10 more nonrestorative sleep, 6 and more restless sleep 11 compared to white individuals. 5, 8 indeed, a study of urban primary care patients found that the odds of reporting clinically significant sleep disturbance (based on the pittsburgh sleep quality index) was 3 times higher in black patients than white patients. 12 findings of insufficient sleep have also been documented in asian americans 13 and native americans. 14 with adequate severity and chronicity, these sleep disturbances can develop into insomnia disorder. while emergent evidence for racial disparities in rates of insomnia disorder is still inconclusive, 15 extant studies suggest that when insomnia disorder occurs in racial minorities it is often more severe compared to their white counterparts. 16à18 for example, relative to white individuals, black individuals have a 67% increased risk of insomnia disorder with short sleep, 17 which is the most severe phenotype. 19 a large prospective study also found that black individuals were 2 times more likely to exhibit chronic insomnia (>1 year) compared to white individuals. 20 another study of insomnia of army soldiers predeployment found that rates of moderate to severe insomnia symptoms were most prevalent in native americans compare to other racial groups. 21 while it is important to describe racial sleep disparities, it is equally important to examine potential mechanisms driving such disparities. 22 without established mechanisms of these disparities, race could be conflated as a risk factor as opposed to a risk marker. the increased risk of adverse health in racial minority groups not caused by their race; instead, race serves as a proxy for the various mechanisms by which these disparities arise. for example, racial minorities face differential exposure to stressors, barriers to education and health literacy, and limited access to health care, all of which increases risk for poor health. this issue has been at the center of ongoing discourse in the field of sleep health, 23, 24 particularly because the distinction has important implications for how intervention approaches might mitigate these disparities. one important potential mechanism for disparities in insomnia is racial discrimination. 22 racial minorities are disproportionately impacted by discrimination based on actual or perceived membership of a particular racial group. 7, 25 although discrimination does occur in acute and distinct incidents, it also commonly exists in more subtle and "everyday" forms (e.g., microaggressions), 26, 27 and thus can function as a chronic stressor. like other stressors, perceived discrimination can trigger and exacerbate insomnia, 28 potentially by increasing vigilance against threat and triggering ruminative cognitions that result in difficulties falling and staying asleep. 29 indeed, studies find that exposure to racial or ethnic discrimination is associated with self-reported insufficient sleep 30 and poorer sleep quality, 31 as well as complaints of insomnia. 32, 33 however, few studies have tested discrimination as a mechanism of racial disparities in insomnia disorder. to date, only one study conducted in a sample of 133 first and second year college students demonstrated that perceived discrimination was a mediator of sleep difficulties measured using a subset of the subscales of the pittsburgh sleep quality index modeled as a latent variable. 34 though research in racial sleep disparities has typically focused on sleep quantity, it is important that this work extends into clinical contexts such as insomnia disorder. first, insomnia disorder rises to a level of severity that not only impairs functioning, but also significantly increases risk for other health complications. for example, insomnia has been implicated as a risk factor for obesity, 35 cardiovascular disease, 36 diabetes, 37 and depression 38, 39 (see 35 for review), all of which also show disparities by race. 41 indeed, as a robust risk factor, disparities in insomnia is likely a fundamental component in the etiology of health disparities. 36 second, while differences in sleep characteristics (e.g., sleep duration) have been described by race, their association with adverse health consequences has been underexplored with mixed evidence 42à44 ; it may be that characteristics of poor sleep is most predictive of poor health in a clinical context. 17, 19, 45 finally, the chronicity and severity of insomnia disorder are stronger motivators for treatment seeking behaviors, which present opportunities for interventions to treat insomnia and prevent the cascade of morbidities leading to health disparities. this present study aimed to examine racial discrimination as a candidate mechanism in the relationship between race and insomnia in a large sample of individuals with dsm-5 insomnia recruited from communities in the greater detroit metropolitan area. perceived discrimination was tested as a mediator of the racial differences of insomnia symptoms severity as measured by the insomnia severity index. we hypothesized that differences in insomnia severity between racial minority groups and white individuals would be significantly mediated by perceived discrimination. data for this study was obtained from communities in detroit metropolitan area and the surrounding communities in southeastern michigan. recruitment included primary care patients from 6 hospitals, 38 medical centers, and subscribers of a major health insurance company in michigan. recruitment materials targeted individuals with sleep difficulties who would be interested in completing a behavioral insomnia intervention delivered via the internet, and data for this study were drawn from the screening questionnaires. all study materials were delivered in english. eligible participants met dsm-5 46 diagnostic criteria for chronic insomnia disorder and were at least 18 years old. exclusion criteria included diagnosed sleep disorders other than insomnia (e.g., restless legs, narcolepsy) or untreated obstructive sleep apnea, severe depression, bipolar or seizure disorders. a total of 1,458 individuals were included in the final analysis, after removing 28 individuals who declined to report their race or reported their race as unknown (see fig. 1 for enrollment chart). experimental protocols were approved by the local institutional review board, and all participants provided informed consent for study participation. the dependent variable was insomnia severity measured using the insomnia severity index (isi). 47, 48 the isi comprises of seven components, with the first 3 items quantifying disturbance by sleep onset, maintenance, and early morning awakenings. the latter 4 queries sleep satisfaction and impact of sleep disorders on quality of life. higher scores on the isi indicate increased insomnia severity (range 0à28). the independent variable was race per self-report in the following categories: white, black or african american, asian, american indian/alaska native, more than one race, unknown (or do not wish to report). analyses compared non-white to white indviiduals, with sensitivity analyses further comparing white to black individuals and white individuals to non-black racial minority groups (see analytical approach below). though racial discrimination is commonly experienced across races, discrimination may manifest differently between racial groups. as such, analyses powered to disaggregate racial groups may reduce masking or distortion of these associations. in all models, race was included as a categorical variable with white as the reference group. the mediator was racial discrimination as assessed via a singleitem measure from the commonwealth fund 2001 health care quality survey 49 and the 2003 california health interview survey. 50 these are validated and population-based surveys that are widely cited in academic research, 51à53 and used in briefings for congress and other governmental agencies to increase equity in health care policies. the prompt was "thinking about your race or ethnicity, how often have you felt treated badly or unfairly because of your race or ethnicity.", and responses included "never" (0), "rarely" (1), "sometimes" (2), "a lot" (3), and "all the time" (4). the construct validity of this measure has been demonstrated using health outcomes known to be associated with other measures of racism. 51, 53, 54 all final models covaried for age, sex, and socioeconomic status (annual household income and education) due to their established relationship with insomnia and racial discrimination as variables of interest. medical comorbidities and body mass index were tested as covariates during model building but were removed in the final analyses due to nonsignificance across all models. annual household income was operationalized as a categorical variable with four ordered levels: very low, low, middle, and high. the lowest category of household income was operationalized as an annual household income less than 15k, which is consistent with the poverty threshold for a 2-person household in 2016. 55 the cutoffs for low, middle, and high income were <35k, <75k, and 75k, respectively. education was similarly operationalized with four ordered levels: high school or less, some college, college, and graduate school. these categories correspond to the international standard classification of education 56 levels 3 or below, 4 and 5, 6, and 7 or higher. the hypothesis was tested using mediation analyses conducted in accordance with procedures outlined by fairchild and mackinnon, 57 with significance testing of the indirect effect using the distribution of the product approach (i.e., the prodclin method) implemented in r. 58 this method is less vulnerable to type i errors compared to traditional significance tests, 59 and does not assume a normal distribution, which allows for asymmetric confidence intervals, 60, 61 statistical significance was determined if the 95% ci for the indirect effect did not include zero. the parameters required for the prodclin approach (pathways a, b, c, and c') were determined via three ordinary least squares regression models with covariates (see fig. 2 ). the direct effect (pathway c) was obtained by regressing race on insomnia severity controlling for covariates. pathway a was obtained by regressing race on racial discrimination controlling for covariates. the remaining parameters were obtained in a third regression that tested the effect of the mediator (racial discrimination) on the outcome variable (insomnia severity) controlling for the predictor (race; pathway b) and covariates, and the effect of the predictor (race) after controlling for the mediator (racial discrimination; pathway c') and covariates. the indirect (i.e., mediated) effect of the predictor on the outcome variable was tested using the product of the a and b parameter estimates. sensitivity analyses were also conducted to examine the specific effects within racial groups. the proportion of the mediated effect was calculated using a ratio of the indirect effect to the total effect. in order to account for potential differences by racial groups, the analytical approach included sensitivity analyses parsed by racial minority groups. a power analysis indicated that a minimum sample size of 78 in each racial minority group was needed to achieve 0.8 power to detect statistical significance. as such, we were able to include one sensitivity analysis that compared the specific effect of black (n = 271) compared to white individuals, and an option of a second analysis that compared the aggregated effect of non-black racial minority groups to white individuals. in building the latter model, exploratory analyses were run by each non-black racial group (asian american, american indian/alaska native, more than one race), and groups that demonstrated similar results were aggregated to achieve adequate statistical power. this approach optimized statistical power while minimized the chance of masking intergroup differences. the final sample included 1,458 individuals with insomnia disorder as defined by the dsm-5. of the total sample, 74.2% were white (n = 1082) and 25.8% were a racial minority (black: n = 271, asian-american: n = 33, american indian/alaska native: n = 14, more than as expected, racial minorities reported significantly more frequent discrimination compared to white individuals (see table 1 ). as a group, insomnia symptoms were more severe in racial minorities (t [1456] = 2.62, p< .01), though the effect (cohen's d = 0.16) was small, likely because the sample comprised those meeting criteria for a diagnosis of insomnia. individuals who reported higher levels of racial discrimination also reported more severe insomnia (t [1456] = 3.29, p = .001); however, the effect size of racial discrimination was over twice the effect size of race (cohen's d = 0.37) (see fig. 3 ). an exploratory post-hoc multivariate regression analysis with the components of the isi found that racial discrimination was associated with higher severity across all components except for difficulty staying asleep and sleep satisfaction. the first regression revealed a significant direct effect where beloning to a racial minority group was associated with higher isi scores (pathway c: b = 0.14 § 0.06 se, p < .05). educational attainment was the only covariate that reached statistical significance, with higher education associated with lower insomnia severity (b = à0.15 § 0.07 se, p < .05). as expected, beloning to a racial minority group was also associated with higher reported discrimination (pathway a: b = 1.09 § 0.05 se, p < .001). finally, while racial discrimination remained a significant predictor of insomnia severity after accounting for race (pathway b: b = 0.07 § 0.03 se, p < .05), racial minority status was no longer significantly associated with a significant direct effect indicated that black individuals reported more severe insomnia symptoms compared to white individuals (pathway c: b = 0.17 § 0.07 se, p < .05). educational attainment was the only covariate that reached statistical significance, with higher education associated with less insomnia severity (b = à0.15 § 0.07 se, p < .05). being black was also associated with higher reported discrimination (pathway a: b = 1.18 § 0.06 se, p < .001). finally, racial discrimination remained a significant predictor of insomnia severity even after adjusting for race (pathway b: b = 0.09 § 0.03 se, p < .01), but being black was no longer a statistically significant predictor of insomnia severity after adjusting for racial discrimination (pathway c': b = 0.07 § 0.08 se, p = .39). the 95% ci of the indirect effect did not overlap with zero (a £ b: 0.10, 95% ci [0.03, 0.18]), and the indirect effect accounted for 60.8% of the relationship between race and insomnia severity in black and white participants. exploratory analyses indicated that individuals who identified as asian american and multiracial exhibited similar patterns of results, and thus were aggregated in the final analysis. results did not show a significant direct effect of race on insomnia severity for asian american or multiracial individuals compared to white individuals (pathway c: b = 0.11 § 0.11 se, p = .31); however, being asian american or multiracial was significantly associated with more reported discrimination compared to white individuals (pathway a: b = 1.18 § 0.10 se, p < .001). educational attainment was the only covariate that reached statistical significance, with higher education associated with less insomnia severity (b = à0.24 § 0.07 se, p < .001). as testing the significance of an indirect effect does not require a direct effect, 62à65 we continued to test for a significant indirect pathway from race through discrimination. racial discrimination remained a significant predictor of insomnia severity even after adjusting for race (pathway b: b = 0.08 § 0.03 se, p < .05), but the relationship between race and insomnia severity was close to zero after accounting for racial discrimination (pathway c': b = 0.02 § 0.12 se, p = .98). the 95% ci of the indirect effect did not overlap with zero (a £ b: 0.09, 95% ci [0.02, 0.17]), and the indirect effect accounted for 84.0% of the relationship between race and insomnia. in contrast, exploratory analyses in american indian/alaska native individuals (n = 14) revealed a small and non-significant decrease in insomnia symptom severity compared to white individuals (b = à0.08 § 0.28 se, p = .75), when controlling for covariates. as was the case with the other models, educational attainment was the only covariate that reached statistical significance, with higher education associated with less insomnia severity (b = à0.25 § 0.08 se, p < .01). after accounting for racial discrimination, the relationship between race and insomnia severity remained nonsignificant, though the coefficient increased in strength (b = à0.17 § 0.27 se, p = .52). this study examined the role of racial discrimination as a potential mechanism for racial sleep disparities in a large clinical sample comprising white and racial minority groups with dsm-5 insomnia. results supported our hypothesis that racial discrimination was indeed a significant mediator in the relationship between race and insomnia severity. in general, we found that racial discrimination explained almost 60% of the differences in insomnia severity between white individuals and racial minority gorups after accounting for covariates, including socioeconomic status (i.e. income and education). indeed, the effect size of the difference in insomnia severity by racial discrimination was twice that of the difference by race. these results are consistent with prior research implicating racial discrimination as a contributor to sleep disturbances in the general population, 32, 33, 66 and extends these findings to racial disparities in insomnia disorder. insomnia is likely an important part of the landscape of health disparities because it may serve as a fundamental pathway to health disparities. 36 insomnia exacerbates stress and potentiates risk for multiple morbidities, including but not limited to depression, anxiety, suicide, substance use disorders, impaired immune functioning, cardiovascular diseases, and chronic pain (see 40, 67 for review). though racial minorities experience an enhanced baseline risk for these morbidities, insomnia may facilitate their progression, 36 particularly as insomnia may manifest more intensely or as more severe phenotypes in racial minorities. 16à18 furthermore, the consequences of insomnia are often higher for those already disenfranchised. 17, 18 for example, whereas absenteeism and diminished work productivity are commonly associated with insomnia, 68 those with the least access to social capital and economic resources are most vulnerable to the cascading consequences such as lost wages or employment termination. 69 insomnia is also important in the landscape of health disparities because it represents an opportunity for both intervention and prevention. 16, 70 in contrast to many other risk factors for health disparities (e.g., socioeconomic status, residential segregation, and food insecurity) insomnia is highly modifiable via behavioral intervention. 71, 72 in fact, our research using cognitive behavioral therapy (delivered digitally for increased accessibility) demonstrated comparable efficacy between black and white individuals 16 despite historically established differences in treatment engagement and adherence in other forms of psychotherapy. 73, 74 furthermore, we have also demonstrated that early intervention of insomnia can prevent incident depression. 70 together, these data suggest that interventions that target and/or mitigate the impact of racial discrimination on insomnia may play an important role in reducing health disparities. though racial discrimination has been well-documented as a predictor of poor health, mental health, and coping, 31 few studies have examined the role of racial discrimination in the development of insomnia. in the 3-p etiological model of insomnia, 28 stress is the most common precipitating factor of sleep disturbances. indeed, evidence from large epidemiological studies have found that psychosocial stress-including racial discrimination-was associated with less sleep, worse sleep quality, and incidence of insomnia symptoms. 33, 75 another study in older black women also found that racial discrimination was associated with worse insomnia symptoms. 32 however, the evolution from acute sleep perturbations to insomnia disorder is understood to be perpetuated by common compensatory behaviors that inadvertently exacerbate and maintain insomnia symptoms (e.g., daytime napping, extending time in bed, etc.), such that the insomnia disorder persists even if the precipitating stressor dissipates. accordingly, precipitating stressors (e.g., racial discrimination) may not be a robust predictor of symptom severity in the context of a clinical disorder. consistent with this model, the direct association between the frequency of racial discrimination and insomnia severity in this clinical sample of dsm-5 insomnia was small, albeit stronger than the association between race and insomnia severity. importantly, racial discrimination is also a chronic or repetitive stressor, and thus may also contribute to the maintenance of insomnia symptoms. these results add additional evidence for racial discrimination as a mechanism driving insomnia in racial minorities and lend support that racial disparities in insomnia are likely a consequence of social inequities (e.g., discrimination) and other determinants of health. interestingly, sensitivity analyses indicated that the indirect effect of racial discrimination was stronger in asian american or multiracial individuals relative to black individuals. while the results from this study do not speak to why racial discrimination might play a differential role between racial minority groups, it is unlikely that racial discrimination is a less potent mediator of insomnia severity in black individuals. black individuals have a long and complex history of social, political, and economic disenfranchisement; notably, racismparticularly anti-black racism has expanded beyond overt forms of discrimination (e.g., accepted use of anti-black slurs, overt racial segregation) to more insidious and covert forms of discrimination (e.g., racial gerrymandering enacted via partisan gerrymandering, 76 mortgage redlining, 77 discriminatory hiring practices 78, 79 ) that relate to social determinants of health (e.g., neighborhood and physical environmental conditions, education and health literacy, access to resources, food, and health care, etc.). however, these covert forms of discrimination may not be adequately captured on an instrument that elicits more proximal experiences of maltreatment due to race. on the other hand, overt forms of discrimination against non-black minorities have persisted (e.g., yellowface in entertainment industry, 80 overt anti-chinese rhetoric and violence during the covid-19 pandemic, 81 native american mascots, 82 etc.). future research should test whether such differences between racial groups are replicated in larger samples. importantly, we had limited statistical power for a more finegrained analysis that parses non-black racial minority groups and that further examines differences by ethnicity. however, because of the paucity of research in non-black racial minorities, we opted to include sensitivity analyses that aggregated non-black racial minority groups that exhibited similar trends; this allowed us to achieve adequate statistical power while minimizing the risk of masking intergroup differences. regrettably, there was insufficient power to parse analyses by both race and ethnicity. the underrepresentation of non-black racial minorities in research samples is likely because investigators largely have not set intentional recruitment goals for non-black racial minorities, 83 and the minority of investigators that have made a priori minority recruitment goals often fall short of those goals. 83 these data imply that research questions (and thus study and recruitment designs) have not focused on these minority groups, perhaps in part because there is little extant research to build from. as such, we also opted to include these sensitivity analyses so they may be considered in the generation of hypotheses for additional research, which should aim to replicate these findings in larger samples and to further examine the complexities and nuances in the mechanisms by which sleep disparities arise within different racial and ethnic minority groups. the present study used a cross-sectional design and is therefore limited in the determination of temporal precedence. however, our results are consistent with prior research indicating that racial discrimination was a significant mediator of the prospective relationship between race and sleep disturbances in a sample of college students, 34 and extend this finding to clinically significant insomnia. additionally, interpretation and generalization of results should take into consideration racial differences in help seeking 84, 85 as the sample comprised individuals interested in receiving a behavioral intervention for insomnia. a common limitation of health disparities research is that many instruments have been developed and validated in predominantly white samples. that said, there is some evidence that the isi shows cross cultural and racial invariance. 86, 87 another limitation may be the use of a single item that broadly measured the frequency of racial discrimination. though commonly used in large epidemiological studies, the use of more complex instruments may capture nuances and dimensions of racial discrimination. overall, this study implicates racial discrimination as an important mechanism driving racial disparities in symptom severity in insomnia disorder, and adds novel information regarding potential differences in the role of racial discrimination between racial minority groups. future research should replicate and extend these findings with a prospective design using more comprehensive instruments measuring racial discrimination along with additional relevant predictors in a sample that better represents the diverse racial groups. the potential for treatment and prevention of insomnia in racial minorities to reduce health disparities should also be explored. social sources of racial disparities in health lack of reduction in racial disparities in cancer-specific mortality over a 20-year period deaths: final data for mortality disparities in racial/ethnic minority groups in the veterans health administration: an evidence review and map sleep symptoms, race/ethnicity, and socioeconomic position sleep and its relationship to racial and ethnic disparities in cardiovascular disease discrimination, other psychosocial stressors, and selfreported sleep duration and difficulties elevated sleep disturbance among blacks in an urban family medicine practice adolescent sleep disparities: sex and racial/ethnic differences sleep disparity, race/ethnicity, and socioeconomic position differences in sleep between black and white adults: an update and future directions elevated sleep disturbance among blacks in an urban family medicine practice short and long sleep duration associated with race/ethnicity, sociodemographics, and socioeconomic position excess frequent insufficient sleep in american indians/alaska natives alc antara c. are sleep patterns influenced by race/ethnicity à a marker of relative advantage or disadvantage? evidence to date efficacy of digital cbt for insomnia to reduce depression across demographic groups: a randomized trial dsm-5 insomnia and short sleep: comorbidity landscape and racial disparities racial/ethnic differences in insomnia trajectories among u.s. older adults insomnia with objective short sleep duration: the most biologically severe phenotype of the disorder risk factors for incident chronic 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discrimination, and tobacco use differences across rural-urban california preliminary estimate of weighted average poverty thresholds for a general model for testing mediation and moderation effects rmediation: an r package for mediation analysis confidence intervals the relative trustworthiness of inferential tests of the indirect effect in statistical mediation analysis: does method really matter? confidence limits for the indirect effect: distribution of the product and resampling methods a comparison of methods to test mediation and other intervening variable effects beyond baron and kenny: statistical mediation analysis in the new millennium equivalence of the mediation, confounding and suppression effect mediation in experimental and nonexperimental studies: new procedures and recommendations reconsidering baron and kenny: myths and truths about mediation analysis discrimination and sleep: a systematic review insomnia as a health risk factor insomnia and its relationship to health-care utilization, work absenteeism, productivity and accidents sickness absence as a risk factor for job termination, unemployment, and disability pension among temporary and permanent employees depression prevention via digital cbt for insomnia: a randomized controlled trial management of chronic insomnia disorder in adults: a clinical practice guideline from the american college of physicians management of chronic insomnia disorder in adults european guideline for the diagnosis and treatment of insomnia delivery of community mental health services to black and white clients racial factors in patient selection the contribution of psychosocial stressors to sleep among african americans in the jackson heart study amicus brief of civil rights organizations (naacp ldf, et al.) in whitford v. gill. social science research network redlining revisited: mortgage lending patterns in sacramento 1930à2004 ban the box, criminal records, and racial discrimination: a field experiment the mark of a criminal record cosmopolitan pleasures and affects; or why are we still talking about yellowface in twenty-first-century cinema? aesthetic cosmop glob cult anti-chinese sentiment during the 2019-ncov outbreak. the lancet dog whistle mascots: native american mascots as normative expressions of prejudice participation in research studies: factors associated with failing to meet minority recruitment goals willingness to seek treatment among black students with anxiety or depression: the synergistic effect of sociocultural factors with symptom severity and intolerance of uncertainty delay between onset of chest pain and arrival to the coronary care unit among minority and disadvantaged patients validating the cross-cultural factor structure and invariance property of the insomnia severity index: evidence based on ordinal efa and cfa confirmatory factor analysis of the insomnia severity index (isi) and invariance across race: a pooled analysis of msflash data support for this study was provided from the robert wood johnson foundation and from the national institute of mental health r56mh115150 awarded to cld. funding for pc was provided from the national heart lung and blood institute (k23hl138166). we would also like to thank the staff at the thomas roth sleep disorders and research center and the henry ford health system for their continued support. key: cord-299976-36r794ow authors: o’brien, amornrat; mettelman, robert c.; volk, aaron; andré, nicole m.; whittaker, gary r.; baker, susan c. title: characterizing replication kinetics and plaque production of type i feline infectious peritonitis virus in three feline cell lines date: 2018-12-01 journal: virology doi: 10.1016/j.virol.2018.08.022 sha: doc_id: 299976 cord_uid: 36r794ow investigating type i feline coronaviruses (fcovs) in tissue culture is critical for understanding the basic virology, pathogenesis, and virus-host interactome of these important veterinary pathogens. this has been a perennial challenge as type i fcov strains do not easily adapt to cell culture. here we characterize replication kinetics and plaque formation of a model type i strain fipv black in fcwf-4 cells established at cornell university (fcwf-4 cu). we determined that maximum virus titers (>10(7) pfu/ml) were recoverable from infected fcwf-4 cu cell-free supernatant at 20 hours post-infection. type i fipv black and both biotypes of type ii fcov formed uniform and enumerable plaques on fcwf-4 cu cells. therefore, these cells were employable in a standardized plaque assay. finally, we determined that the fcwf-4 cu cells were morphologically distinct from feline bone marrow-derived macrophages and were less sensitive to exogenous type i interferon than were fcwf-4 cells purchased from atcc. feline coronaviruses (fcovs) are members of the alphacoronavirus genus that infect cats and can cause the highly lethal disease known as feline infectious peritonitis (fip) (pedersen, 2009 ). fcov infection is widespread among domestic feline populations, especially within multicat households and catteries, which can exhibit upwards of 96% seropositivity (addie et al., 2003; addie and jarrett, 1992; hohdatsu et al., 1992; pedersen, 2009 pedersen, , 1976 vennema et al., 1998) . despite the global burden of fcov infection, there are no currently approved therapeutics to treat fip; however, reports of direct inhibition of virus growth and treatment of individual cats using small molecule viral inhibitors have been promising (kim et al., 2016 (kim et al., , 2015 (kim et al., , 2013 (kim et al., , 2012 murphy et al., 2018; pedersen et al., 2017; st john et al., 2015) . fcovs are typically grouped into two biotypes (or pathotypes), which have been classified as feline enteric coronavirus (fecv) and feline infectious peritonitis virus (fipv), based on tissue tropism, disease progression, and genetic markers (reviewed in kipar and meli, 2014; pedersen, 2014 pedersen, , 2009 , although the range of disease signs and clinical outcomes are likely to extend beyond these two basic definitions. endemic fecv causes mild enteritis associated with loose stool and diarrhea and commonly leads to an asymptomatic, persistent infection (addie, 2011; addie et al., 2003; pedersen et al., 2008) . a subset of these infections (3-10%) result in lethal fip (addie and jarrett, 1992; pedersen, 1976) arising from a shift in virus tropism and systemic infection of monocytes and macrophages. perturbations of the host feline immune state leading to immune deficiency can allow virus replication to surge (pedersen, 2009; tekes and thiel, 2016) , resulting in the formation of a quasispecies and the genetic sampling required for progression of fecv to the second biotype, fipv. the internal mutation theory proposes that, within an individual animal, fipv arises directly from fecv due to accumulation of non-synonymous mutations in spike (s) (licitra et al., 2014 (licitra et al., , 2013 rottier et al., 2005) and group-specific proteins (chang et al., 2010; herrewegh et al., 1995; lin et al., 2009; pedersen et al., 2012; phillips et al., 2013; poland et al., 1996; vennema et al., 1998) . the resulting infection of monocytes and macrophages by fipv leads to systemic spread and development of immune-mediated fip (pedersen, 2009) . fcov biotypes are further defined by their viral s protein. classically, antigenicity of the s protein alone has been used to categorize fcovs into two serotypes (type i and type ii) (hohdatsu et al., specific grouping of fcovs into two clades via functionality-based sprotein sequencing (whittaker et al., 2018) . type i viruses account for the bulk (80-90%) of natural infections in domestic cats, while type ii fcov, a naturally-occurring recombinant between the type i and canine coronavirus (ccov) spike proteins (herrewegh et al., 1998) , is far less prevalent (< 10%) (addie et al., 2003; benetka et al., 2004; hohdatsu et al., 1992; kennedy et al., 2002) . a commendable number of studies focus on type ii fcov as these viruses are much more easily propagated in cell culture. however, it is difficult to know how accurately type ii laboratory strains reflect natural infections with type i viruses given that the bulk of what is known about type i is extrapolated from studies using a type ii virus. it is critical that we investigate type i fipv in laboratory cell culture in order to understand the basic virology of natural infection, characterize type i clinical isolates, test novel therapeutics, and develop effective feline vaccines with broader coverage. however, this has been challenging because type i fcovs cannot be easily adapted to laboratory cell culture; furthermore, the receptor for type i is not known (cham et al., 2017; dye et al., 2007; hohdatsu et al., 1998) , making the identification of highly permissive cell types difficult. select type i isolates, such as the fipv black strain used in this study, have been adapted to growth in tissue culture at the cost of reduced in vivo virulence (black, 1980; pedersen, 2009; tekes et al., 2007; thiel et al., 2014) . feline airway epithelial (ak-d) cells propagate fipv black (regan et al., 2012) ; however, these cells do not represent natural tropism for fipv. felis catus whole fetus 4 (fcwf-4) cells are a more physiologically-relevant feline macrophage-like cell line (jacobse-geels and horzinek, 1983), but these cells come with several technical drawbacks for studying type i fipv. first, fcwf-4 cell doubling time is slow (> 31 h) (american type culture collection, 2013) and cells do not grow to high density. second, previous studies report that type i fipv grows to low titers (< 10 5 pfu/ml) in these cells relative to type ii (> 10 6 pfu/ml) (tekes et al., 2012) and can be measured by determining the 50% tissue culture infectious dose (tcid 50 ) (ramakrishnan, 2016; reed and muench, 1938) or by plaque assay (tekes et al., 2012 (tekes et al., , 2010 . third, type i virus kinetics are variable in fcwf-4 cells, requiring between 15 and 72 h to achieve maximum titer (jacobse-geels and horzinek, 1983; tekes et al., 2012 tekes et al., , 2007 this study) . finally, some reports suggest that type i is highly cell-associated (jacobse-geels and horzinek, 1983; pedersen et al., 1984) and multiple freeze-thaw cycles may be required to recover virus. together, these factors have made investigation of type i fipv challenging. as part of this study, we characterized three feline cell lines-two from the american type culture collection (atcc) and one from cornell university-and evaluated the replication kinetics, efficiency of plaque formation, and responsiveness of these cells to interferon (ifn) in order to identify the optimal cell culture conditions for type i fipv black. we found that an fcwf-4 cell line established at cornell university college of veterinary medicine, designated fcwf-4 cu, propagates type i fipv to significantly higher titers in cell-free supernatant and with more rapid kinetics compared to commercially available fcwf-4 cells. we show that fcwf-4 cu cells are less responsive to exogenous type i interferon than fcwf-4 cells from the atcc and are permissive to infection by both biotypes of type ii fcov. to facilitate cell-free titer was determined from cell-clarified supernatants; cell-associated titer was determined from suspended cell monolayers following three freeze-thaw cycles alternating between −80°c and 37 o c. samples were taken at hours post-infection (hpi) just prior to, at, and following the maximum (max) virus titer for each cell type. titers determined by plaque assay on ak-d cells in triplicate; error bars ± sd. quantitation of fipv black, we established a standardized plaque assay method using fcwf-4 cu cells and commercially available ak-d cells and show that both cell types permit rapid and consistent quantitation of infectious titers of type i fipv as well as type ii fipv and fecv from cell-free supernatants. to determine the optimal cell type and conditions required to grow the type i fipv black strain, we evaluated virus growth kinetics using a standard infection time course. cells were infected at a multiplicity of infection (moi) of 0.1 and virus titer was determined by plaque assay from cell-free supernatants over 96 h. fipv black, a distinct type i lab strain that replicates in feline epithelial cells, replicated as expected in ak-d cells reaching a maximum titer > 10 6 pfu/ml at 36 h post-infection (hpi) (fig. 1a) . in our hands, using fcwf-4 cells purchased from the atcc, the replication of fipv black reached a maximum titer > 10 4 pfu/ml over 72-96 hpi (fig. 1a) . strikingly, fipv black replication kinetics and maximum titer were drastically different in an fcwf-4 cell line established at cornell university college of veterinary medicine (fcwf-4 cu). using these cells, the virus reached a significantly higher maximum titer of > 10 6 pfu/ml at 20 hpi. in other words, nearly 100 times more virus was produced from the fcwf-4 cu cells a full 2-3 days faster than in fcwf-4 atcc cells. to address whether the differences in titer observed between ak-d, fcwf-4 cu, and fcwf-4 atcc cells were due to differences in cell-free and cell-associated virus, we compared the cell-associated and cell-free virus titers from each cell type at the time points around the respective maximum titers. surprisingly, the cell-free virus titers were higher than the cell-associated titers at all time points and in all cell types assayed (fig. 1b) . this indicates that fipv black virions are released into cell supernatant during infection of cell culture and freeze-thaw cycles are not necessary to obtain high virus titers. although the maximum titers of fipv black were comparable between ak-d and fcwf-4 cu cells, the progression of cell cytopathic effects (cpe) induced by the virus differed. fipv black formed large, uniform syncytia in fcwf-4 cu cells, while individual cell-death-induced clearings were observed in infected ak-d cells ( fig. 2a ). of note, maximum titers from both cell types were obtained just prior to the appearance of major cpe, allowing a visual guide to virus collection. to further demonstrate this point, fcwf-4 cu and ak-d cells infected with fipv black were labeled with an anti-nucleocapsid antibody (ccv2-2) (poncelet et al., 2008) and visualized by immunofluorescence prior to the induction of major observable cpe. as expected, the majority of cells were positive for virus antigen (fig. 2b ) and the differences in cpe are clearly shown: note the syncytial membrane fusion in infected fcwf-4 cu cells and the maintenance of distinct cell membranes in infected ak-d cells (fig. 2b) . together, these results demonstrate the ability of the fcwf-4 cu cells to rapidly produce high levels of type i fipv black in cell-free supernatants. after observing the rapid and uniform development of cpe and release of virus into cell supernatants during infection of ak-d and fcwf-4 cu cells, we reasoned that these cells would be employable in a standardized plaque assay to consistently determine fipv black titer. to this end, we calculated the endpoint titer and compared the size, uniformity, and timing of virus plaque development over time in ak-d, fcwf-4 atcc, and fcwf-4 cu cells following infection with 10-fold dilutions of the same fipv black virus stock initially grown on fcwf-4 cu cells. a detailed description of the plaque assay is provided in the materials and methods; we note here that oxoid agar is critical for visualizing clear plaques. at 2 days post-infection (dpi), fipv black formed enumerable plaques on both ak-d and fcwf-4 cu cells with the latter cells producing more numerous and larger plaques at higher dilutions (fig. 3 top) . plaques were not observed in fcwf-4 atcc cells at 2 dpi (fig. 3 top) . plaques were detected at 3 dpi (fig. 3 middle) ; and were more clear at 4 dpi in fcwf-4 atcc cells (fig. 3 bottom) . calculated titers overall were higher in fcwf-4 cu (> 10 7 pfu/ml) than in ak-d cells (≥10 6 pfu/ml); however, we report that both cell types are useful for determining virus titer, whereas the fcwf-4 atcc cells are not ideal for use in this assay. the apparent differences in production and kinetics of fipv black virus in two fcwf-4 cell lines led us to ask if there are morphologic or functional differences between the two cell types. to answer this question, we first compared the single-cell morphologies of fcwf-4 atcc, fcwf-4 cu cells, and primary feline bone marrow-derived macrophages (fbmdms) by wright-giemsa staining. the typical morphologic characteristics of feline macrophages (large cytoplasmic inclusions, a non-dominant nucleus, a non-ruffled cell membrane) (bienzle et al., 2003) were observed for the fbmdms (fig. 4a) . comparison of the two fcwf-4 cell lines revealed stark differences in morphology. fcwf-4 atcc cells were large with a smooth cell membrane and had large and abundant cytoplasmic inclusions comparable to the fbmdms (fig. 4a ). fcwf-4 cu cells were more similar in size to fbmdms; however, the fcwf-4 cu cell line exhibited fewer cytoplasmic inclusions and more cell membrane ruffling (fig. 4a ) than either the fbmdms or fcwf-4 atcc cells. neither fcwf-4 cell line had a "true" macrophage morphology further corroborating their original "macrophage-like" description (jacobse-geels and horzinek, 1983). as macrophages are innate immune cells that restrict virus replication through production of interferon-stimulated genes (isgs) in response to type i ifn, we reasoned that differences in virus replication may be due to variation in cell ifn-responsiveness. therefore, we asked if fcwf-4 atcc and cu cell lines differed in responsiveness to exogenous type i ifn by measuring the resulting isg54 transcript production following treatment with ifn. remarkably, fcwf-4 atcc cells produced significantly higher isg54 transcripts in response to ifn stimulation compared to fcwf-4 cu cells (fig. 4b) , suggesting that the fcwf-4 cu cells are much less responsive to ifn. this is not to say, however, that fcwf-4 cu cells are insensitive to ifn since they also exhibit significant, dose-dependent isg54 transcript production. together, these data highlight the distinct morphology of the fcwf-4 cu cells and suggest that enhanced virus replication in these cells may be due, at least in part, to reduced ifnresponsiveness. due to the high titer and rapid kinetics of type i fipv black replication in the fcwf-4 cu cells, we next addressed whether these cells are permissive to type ii fcov infection. fcwf-4 cu cells were infected with type i fipv black or one of two type ii viruses, fipv 79-1146 or fecv 79-1683. cell cytopathic effects were observed over time in these cells, with the viruses all forming similar, large syncytia (fig. 5a) . cellfree virus titers were determined at 12 and 24 hpi. all three viruses accumulated to titers > 10 6 pfu/ml in supernatants by 24 hpi (fig. 5b) , with fipv 79-1146 reaching the highest titer. the kinetics of the type ii viruses were faster than the type i fipv black strain, producing higher titers by 12 hpi (fig. 5b) and inducing more substantial syncytial cpe by 16 hpi (fig. 5a) . next, we asked if the fcwf-4 cu cells could be utilized in a plaque assay for determining the titer of type ii fcov. indeed, both fipv 79-1146 and fecv 79-1683 formed clear, uniform, enumerable plaques at 24 hpi (fig. 5c) . thus, we have demonstrated that the fcwf-4 cu cells replicate both fcov types and biotypes to high titers and are employable in a plaque assay to consistently determine the titers of all viruses assayed. since the isolation of the fipv black strain in 1980 (black, 1980) it has remained a predominant model of type i fipv because it is cultivatable in commercially available fcwf-4 cells. however, different groups have reported major variations in the growth kinetics, maximum obtainable titer, and techniques for recovery of this virus from tissue culture (jacobse-geels and horzinek, 1983; pedersen et al., 1984; tekes et al., 2012 tekes et al., , 2007 thiel et al., 2014) . for example, maximal titers measured by determining the tcid 50 can range between > 10 3 (jacobse-geels and horzinek, 1983) and 10 4 tcid 50 /ml (takano et al., 2015) at 24-48 hpi, or measured by plaque assay between > 10 4 (36 hpi) (tekes et al., 2012 (tekes et al., , 2007 and > 10 7 pfu/ml (20 hpi) (this report). this suggests either high variability in the fcwf-4 cell lines used or co-adaptation between a particular virus and fcwf-4 cell line used during laboratory cultivation. indeed, we report significant differences in fipv black replication properties between an fcwf-4 cell line that was newly purchased from the atcc, and the fcwf-4 cells that were established at cornell university. the enhanced rate of fipv black virus growth and increased maximum titer (> 10 7 pfu/ml by 20 hpi) obtained from infected fcwf-4 cu cells, however, may not be due to coadaptation with our particular strain of fipv black, as these cells also replicated both biotypes of type ii viruses. instead, the fcwf-4 cu cells may be highly susceptible to fcov infection in general and therefore may be particularly useful in generating highly-permissive cell types to isolate and grow clinical type i fcovs. the increased virus infection of fcwf-4 cu cells could be due to any number of cellular factors; however, it is tempting to speculate that the reduced ifn-responsiveness of the fcwf-4 cu cells relative to the fcwf-4 atcc cells may significantly enhance infection in the former. further, these fcwf-4 cu cells may express a higher density of the yet unknown type i virus receptor (cham et al., 2017; dye et al., 2007) and therefore may be critical in identifying the receptor or other cellular characteristics that allow for enhanced type i virus replication. fipv black infection of fcwf-4 cells has also been reported to be highly cell-associated (jacobse-geels and horzinek, 1983; pedersen et al., 1984) , requiring suspension and freeze-thaw cycling to release infectious virus. in contrast, we found significantly higher titers of virus in cell-free supernatants and speculate that multiple freeze-thaw cycles may actually decrease virus titer by damaging the virus envelope. the release of virus into cell supernatants and the uniform cpe observed in ak-d and fcwf-4 cu cells were critical in establishing a standardized plaque assay using either cell type. further, we report that the stage of cpe development can be used as an indicator of when maximal virus titers can be recovered. one possible explanation for the varied reports on titer of fipv black is that laboratory lines of fcwf-4 cells have deviated from the original atcc stock. this is likely what occurred at cornell university to produce the fcwf-4 cu cell line, given that fcwf-4 cells were obtained from the atcc and then passaged for many years. to our knowledge, this is the first report describing the phenotypic differences between the original fcwf-4 cells available from the atcc and a distinct lineage that was derived from the original cells. many challenges are still associated with the growth of type i fcov in tissue culture, including the lack of a known cell-entry receptor and no highly permissive cell type that rapidly grows clinical samples of these viruses. however, our studies with the fcwf-4 cu cell line demonstrate that rapid, high titers of type i fipv black can be recovered from cell-free supernatants and enumerated using a standardized plaque assay. it is our hope that the fcwf-4 cu cells will alleviate some of the technical hardships associated with the growth of type i fcov and expedite investigation of a wider range of type i fcov strains. the fcwf-4 cu cells, due to their distinct growth kinetics and enhanced replication of fipv black virus, will be deposited at the atcc to facilitate their distribution to the research community. feline coronavirus strains including type i feline infectious peritonitis virus (fipv) , type ii fipv wsu 79-1146, and type ii feline enteric coronavirus (fecv) wsu 79-1683 were kindly provided by dr. fred scott, cornell university college of veterinary medicine, ithaca, ny. feline airway epithelial (ak-d) cells were purchased from the american type culture collection (atcc) (atcc ® ccl-150™) and maintained in dulbecco's modified eagle medium (dmem; gibco, #12100-046) containing 10% fetal bovine serum (fbs) (atlanta biologicals, #s11150), supplemented with 2.2 g/l of sodium bicarbonate (sigma, #s5761), 1% non-essential amino acids (hyclone, #sh30238.01), 1% hepes (hyclone, #sh30237.01), 1% sodium pyruvate (corning, #25-000-ci), 1% l-glutamine (hyclone, #sh30034.01), and 1% penicillin/ streptomycin (corning, #30-002-ci). when cells grew to a confluent monolayer, the medium was removed and the monolayer was rinsed with pbs. the cells were removed by addition of 2 ml of 0.25% trypsin (gibco, #15090-046) in versene solution (0.48 mm edta in pbs) for 1-2 min at room temperature. for routine passaging, approximately 5.0 × 10 5 -1.0 × 10 6 cells were transferred (1:5 split) to a new t-75 flask every 3 days. felis catus whole fetus (fcwf-4) cells were purchased from the atcc (atcc ® crl-2787™), designated fcwf-4 atcc cells. fcwf-4 atcc cells were maintained in minimal essential medium eagle (emem) (sigma, #m0268) containing 10% fbs, supplemented with 1.5 g/l sodium bicarbonate, 1% non-essential amino acids, 1% hepes, 1% sodium pyruvate, 1% lglutamine and 1% penicillin/streptomycin. as described by the atcc, the doubling time for these cells is > 31 h. when cells were confluent in t-25 flask, the monolayer was washed with pbs, then cells were removed by addition of 1.5 ml 0.25% trypsin-versene solution for 2-3 min at room temperature. for routine passaging, approximately 1.0 × 10 5 -5.0 × 10 5 cells were transferred (1:3 split) to a new t-25 flask every 3 days. a second source of felis catus whole fetus cells were provided by dr. edward j. dubovi, cornell university college of veterinary medicine, ithaca, ny, designated fcwf-4 cu, and maintained in the same medium as the fcwf-4 atcc cells. when cells were confluent, the monolayer was washed with pbs, then cells were removed by addition of 2 ml 0.25% trypsin-versene solution for 1-2 min at room temperature. for routine passaging, approximately 5.0 × 10 5 -1.0 × 10 6 cells were transferred (1:10 split) to a new t-75 flask every 3 days. all cells used in this study were monitored for mycoplasma contamination using a pcr-based assay. cell culture supernatants were routinely collected after 3 days of culture and then heat-inactivated at 95°c for 10 min. pcr amplification for mycoplasma detection was performed using a forward primer: 5'-ggc gaa tgg gtg agt aac acg -3' and a reverse primer: 5'-cgg ata acg ctt gcg acc tat g -3'. thermocycler settings were as follows: initial denaturation at 95°c for 10 min; 35 cycles consisting of denaturation at 95°c for 45 s, annealing at 60°c for 45 s, and extension at 72°c for 60 s; and a final extension at 72°c for 10 min. the pcr products were analyzed on 1% (w/v) agarose gel. dna fragments were visualized with a uv transilluminator after being stained with ethidium bromide. if mycoplasma was detected, the cells were treated for 7 days with 0.5 μg/ml of mycoplasma removal agent (bio-rad, #buf035). all results shown here are from mycoplasma negative cells. iacuc approved protocols. total bone marrow content was collected. red blood cells and fatty tissue were removed by lysis in ack lysis buffer and straining through a 0.70 µm filter (falcon). the remaining cells, predominantly hematopoietic stem cells, were cryopreserved at 5.0 × 10 7 cells/ml in 90% fbs and 10% dmso. feline bone marrow derived macrophages (fbmdms) were differentiated as previously reported (gow et al., 2013) with slight modification. briefly, 5.0 × 10 7 bone marrow cells were plated in 100 × 26 mm petri dishes (vwr, #25387-030) in dmem (corning, #10-017-cv) supplemented with 20% fbs, 10,000 iu/ml recombinant human (rh) m-csf (peprotech, #300-25) and 50 μm β-mercaptoethanol then incubated at 37°c and 5% co 2 . at day 3, supernatant was removed, clarified of cells, diluted 1:1 with fresh dmem supplemented with 20% fcs and 10,000 iu/ml rhm-csf, and returned to cells. fbmdms were recovered on day 6 by gentle aspiration in pbs following 30 min, 4°c incubation in pbs. the plaque assay technique was established using both ak-d and fcwf-4 cu cells. 6.5 × 10 5 cells per well were plated in 6-well plates or 3.0 × 10 5 cells per well were plated in 12-well plates. cells were infected with 10-fold serial dilutions of viral samples for 1 h at 37°c, followed by overlaying with a 0.5% oxoid agar (oxoid ltd, #lp0028)-dmem containing 1% fbs mixture. plates were incubated at 37°c for 48 h (or the indicated time) and fixed using 3.7% formaldehyde-pbs solution for 30 min. viral plaques were visualized by staining with 0.1% crystal violet for 30 min and photographed. we note plaques were clearly evident when we used oxoid agar, but not if we used noble agar. we analyzed the growth kinetics of type i fipv black in three cell lines: ak-d, fcwf-4 cu, and fcwf-4 atcc. type ii fcov titers were evaluated in fcwf-4 cu cells. for all cell types, 1.5 × 10 5 cells were plated in 24-well plates or 3.0 × 10 5 cells in 12-well plates. after incubating for 24 h, cells were infected with fipv in serum-free media at a multiplicity of infection (moi) of 0.1 at 37°c. after a 1 h incubation, the infectious media were replaced with fresh media containing 2% fbs. at the indicated time points, cell-free supernatants and/or infected cells were harvested and used for titration by plaque assay on ak-d (fipv black) or fcwf-4 cu (type ii fcovs) cells. the supernatant was collected from the cultures at the time indicated and subjected to centrifugation at 2200 ×g for 10 min at 4°c to remove any dead cells. this cell free supernatant was aliquoted and frozen at −80°c until use. to prepare the cell-associated sample, 0.5 ml of medium was added to the infected cells in the 24-well plate, and the entire plate was frozen at −80°c. the infected cells were then subjected to two additional rounds of freezing and thawing (37°c for 1-2 min). after the third thaw, the cells and medium were transferred to a centrifuge tube and centrifuged at 2200 ×g for 10 min at 4°c to remove cell debris. the supernatant containing the viruses released from the cells during the freeze-thaw process was designated the cellassociated virus sample. monolayers of 1.0 × 10 5 ak-d and fcwf-4 cu cells were cultured in 8-well chamber slides (nalge nunc international, #177445) at 37°c for 24 h. cells were infected with fipv black at a moi of 0.1 for 1 h at 37°c. at times indicated, the infected cells were fixed with 3.7% formaldehyde-pbs solution for 30 min, permeabilized with 0.1% triton x-100 in pbs for 10 min, and then incubated with blocking solution containing 5% normal goat serum and 0.1% triton x-100 in pbs at 4°c overnight. for immunofluorescence staining of fipv black-infected cells, the cells were incubated with mouse monoclonal anti-fipv nucleocapsid (ccv2-2) (poncelet et al., 2008 ) (bio-rad, #mca2594b) as a primary antibody at a dilution of 1:500 at room temperature for 1 h. cells were then incubated with a secondary antibody, alexa fluor 568conjugated goat anti-mouse igg (thermo fisher scientific, #a11004) at a dilution of 1:1000 in the presence of hoechst33342 (thermo fisher scientific, #h1399) at a dilution of 1:1000 for nucleus stain. after 30 min incubation with the secondary antibody at room temperature, the cells were then washed with pbs, mounted, and examined under a fluorescence microscope. 4.8. quantification of isg54 transcript production by rt-qpcr following stimulation with feline ifn cells (1.0 ×10 5 in a 24-well plate) were treated with 10, 100, or 1000 u/ml of purified feline ifn-alpha (pbl assay science, #15100-1) for 6 h. to determine isg54 and feline β-actin mrna production, total rna was extracted and an equal amount of rna (1000 ng) was used for cdna synthesis using rt 2 ht first-strand kit (qiagen, #330401). qpcr was performed with specific primers for feline β-actin transcript (fwd 5'-caa ccg tga gaa gat gac tca ga -3'; rev 5'-ccc aga gtc cat gac aat acc a -3') or isg54 transcript (fwd 5'-cct gag ctg cag cct ttc aga aca g -3'; rev 5'-cac gtg aaa tgg cat tta agt tgc cgc ag -3') using rt 2 sybr green qpcr mastermix (qiagen, #330502). a bio-rad cfx96 thermocycler was set as follows: one step at 95°c (10 min); 40 cycles of 95°c (15 s), 60°c (1 min), and plate read; one step at 95°c (10 s); and a melt curve from 65°c to 95°c at increments of 0.5°c/0.05 s. samples were evaluated in triplicate and data are representative of three independent experiments. the levels of mrna are reported relative to β-actin mrna and expressed as 2 −δct [δc t = c t(gene of interest) −c t(β-actin) ]. feline bone marrow-derived macrophages, fcwf-4 cu, or fcwf-4 atcc cells, grown for 24 h in 100 × 26 mm petri dishes (vwr, #25387-030), were washed with pbs, incubated in pbs for 30 min at 4°c, then collected with gentle pipetting. using a cytospin (shandon), 200 μl of cells (10,000 cells/ml) suspended in pbs supplemented with 2% bsa were spun onto glass coverslips (pre-treated with 2% bsa in pbs) at 115 xg for 6 min. cells were dried, rinsed in pbs, then fixed in absolute methanol for 1 min. wright-giemsa (thermo fisher scientific, #9990710) staining was performed per the manufacturer's instructions using a 3 min primary stain and a 2 min counter stain, and washed with 1) . b) fcov growth kinetics in fcwf-4 cu cells (moi=0.1) determined by c) plaque assay on fcwf-4 cu indicator cells. tenfold serial dilutions of cellfree virus inoculum were applied to cells. following oxoid agar/media overlay, cells were fixed in 3.7% formaldehyde and stained using 0.1% crystal violet after 24 h. fcov used were the type i strain fipv black and the type ii strains fipv wsu 79-1146 and fecv wsu 79-1683. plaque assay performed in triplicate; error bars ± sd. a. o'brien et al. virology 525 (2018) 1 ml rinse solution. slides were dried and imaged under oil immersion at 100x magnification. infectious diseases of the dog and cat. saunders a study of naturally occurring feline coronavirus infections in kittens persistence and transmission of natural type i feline coronavirus infection american type culture collection prevalence of feline coronavirus types i and ii in cats with histopathologically verified feline infectious peritonitis immunophenotype and functional properties of feline dendritic cells derived from blood and bone marrow recovery and in vitro cultivation of a coronavirus from laboratoryinduced cases of feline infectious peritonitis (fip) determination of the cell tropism of serotype 1 feline infectious 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background display accelerated viral growth and altered receptor usage genome organization and reverse genetic analysis of a type i feline coronavirus a reverse genetics approach to study feline infectious peritonitis feline coronaviruses: pathogenesis of feline infectious peritonitis tackling feline infectious peritonitis via reverse genetics feline infectious peritonitis viruses arise by mutation from endemic feline enteric coronaviruses improving virus taxonomy by recontextualizing sequence-based classification with biologically relevant data: the case of the alphacoronavirus 1 species we thank matthew hackbart, dr. xufang deng, dr. jean k. millet and javier jaimes for helpful discussions. we also thank dr. fred scott and dr. edward j. dubovi for the provision of reagents. tissue samples and associated phenotypic data were provided by the cornell veterinary biobank, a resource built with the support of national institutes of health (nih) grant r24 gm082910 and the cornell university college of veterinary medicine. this work was supported by a pilot project grant issued to s.c.b. by loyola university of chicago and a research grant from the winn feline foundation bria fund (#mtw17-022 to s.c.b. and g.r.w.). r.c.m. is supported by the (nih) t32 training grant for experimental immunology (#ai007508) and the arthur j. schmitt dissertation fellowship in leadership and service (arthur j. schmitt foundation). g.r.w. is supported by research grants from the cornell feline health center and the winn feline foundation. key: cord-031722-n5ja5oqw authors: fields, errol l.; hussen, sophia a.; malebranche, david j. title: mind the gap: hiv prevention among young black men who have sex with men date: 2020-09-10 journal: curr hiv/aids rep doi: 10.1007/s11904-020-00532-z sha: doc_id: 31722 cord_uid: n5ja5oqw purpose of review: young black men who have sex with men (ybmsm) suffer profound health inequities in new hiv diagnoses and clinical outcomes. while the evolution of hiv prevention options has become increasingly biomedical, inequities in access and uptake of these modalities persist. recent findings: studies suggest that while ybmsm display interest and acceptability of varied hiv prevention options, uptake lags due to the lingering effects of intersectional oppression from racism and sexual prejudice, hiv stigma, institutional and provider bias, and unresolved health policy barriers. promising avenues to address these barriers have yet to be fully explored. summary: we have the tools to effectively prevent hiv transmission and acquisition among ybmsm, but we have not yet effectively implemented these tools for this priority population. to end the epidemic, we must tailor and adapt hiv prevention strategies to meet the unique intersecting needs, identities, and social contexts of ybmsm. between 2012 and 2016, hiv diagnoses among adolescents and young adults (aya), defined as individuals aged between 13 and 24 years, increased 6%, whereas hiv diagnoses among older adults declined or stabilized over the same period [1] . in 2018, 21% of the 37,832 new hiv diagnoses in the united states (u.s.) were among aya. moreover, men who have sex with men (msm) made up 92% of cases among aya, of which 51% were young black men who have sex with men (ybmsm). despite an 11% reduction in new hiv diagnoses among ybmsm from 2010 through 2017, racial disparities in hiv incidence and prevalence have persisted, highlighting a need for tailored approaches that match the specificity of the epidemiology and prioritize this vulnerable population. in the past decade, several major advances have emerged in hiv prevention. treatment as prevention (tasp) was introduced with the hiv prevention trials network (hptn) 052 study, which demonstrated that people living with hiv, when treated early with antiretroviral therapy (art) and maintaining viral suppression, markedly reduced their likelihood of transmitting hiv to their heterosexual partners [2] . subsequent studies found that serodifferent same-sex and heterosexual couples demonstrated no new hiv infections over 150,000 condomless sex acts, when the partner living with hiv demonstrated viral suppression on art [3] [4] [5] . this evidence has resulted in the firm conclusion that treatment is prevention, and that those who maintain an undetectable hiv viral load do not transmit hiv to their sexual partners (i.e., undetectable = untransmittable [u=u]) [6] . pre-exposure prophylaxis (prep) has also demonstrated impressive results in reducing hiv transmission, with daily oral pill regimens tenofovir disoproxil/emtricitabine (tdf/ftc) and tenofovir alafenamide/emtricitabine (taf/ftc) reducing the risk of this article is part of the topical collection on the science of prevention hiv acquisition up to 99% with daily adherence, leading to a grade a recommendation from the u.s. prevention services task force (uspstf) [7] [8] [9] [10] [11] . emerging technologies, including long-acting injectable prep (cabotegravir) awaiting fda approval, will further augment and diversify prevention modalities and strategies [12] . dr. anthony fauci, director of the national institute of allergy and infectious diseases, noted in a 2016 op-ed, "we have the tools to end the hiv/aids pandemic… [but] our proven tools have not been implemented adequately or uniformly" [13] . this inequity is apparent in the disparate hiv burden that ybmsm experience. despite the expansion of the hiv prevention toolkit, inadequate access to and/or uptake of these tools among ybmsm threatens to exacerbate rather than eliminate these inequities. the objective of this review is to describe the state of hiv prevention for adolescent (aged 13-17 years) and young adult (aged 18-24 years) ybmsm, including hiv testing and biomedical, behavioral, and structural approaches. we will highlight gaps in implementation of current tools and make recommendations for maximizing prevention strategies for this priority population. hiv testing is an important initial step in both the hiv treatment and prevention cascades. yet studies have described low rates of testing among aya msm in general and among ybmsm in particular. testing rates may be higher among ybmsm compared with young msm in other racial/ethnic subgroups [14] , but relative to their higher relative hiv incidence, testing rates remain insufficient. a number of factors associated with hiv testing among msm have been examined. however, studies have often focused on subgroups defined by age or race/ethnicity and rarely the intersection of these subgroups where ybmsm populations are positioned [14] . further delineations of adolescent (13) (14) (15) (16) (17) and young adult (18) (19) (20) (21) (22) (23) (24) ybmsm communities are rarer still. nevertheless, several factors described in existing studies may be important considerations for ybmsm. national surveys of hiv testing in aya msm report individual and interpersonal level testing barriers including fear of judgment from peers and family, nondisclosure of sexual identity or behavior to parents/guardians or providers, limited sexual health communication with parents/guardians or providers, fear of a positive test result, and low risk perceptions and knowledge of hiv risk [15] . structural level barriers include cost, transportation, limited access to inclusive, comprehensive, youth-specific sexual health services, and lack of inclusive sexual health and hiv-specific health education [16] . smaller surveys and qualitative studies in ybmsm or older adult black msm have described similar barriers including concerns over issues of cost, accuracy, comfort within testing venues, and poor communication from providers related to sexual health [17] [18] [19] . these studies have also described the influence of social contexts (e.g., fear of stigma from families, friends and communities, and the potential consequences of positive test results) on hiv risk perceptions and testing practices [15] . similar barriers have also been noted with newer testing modalities such as home or self-testing [20] . the efficacy of tasp and u=u depends on an intact and robust hiv care continuum including early diagnosis, care linkage, engagement, and sustained viral suppression among people living with hiv. however, ybmsm living with hiv are often less likely to be diagnosed, engaged in care, or virally suppressed compared with other age and race/ethnicity subgroups [21] [22] [23] [24] . several studies have examined barriers and facilitators of treatment engagement, adherence, and viral suppression in this population [21, [25] [26] [27] [28] . among ybmsm living with hiv, barriers to adherence and viral suppression include depressive symptoms and psychological distress [25] , substance use [22, 25] , housing instability, hiv stigma [28] , and being uninsured or underinsured. facilitators to adherence and viral suppression include access to social and tangible support, self-efficacy with communicating with providers, being insured, and higher education level. consequently, due to gaps in the hiv care continuum, hivnegative ybmsm may have sex with individuals in sexual networks with higher rates of undiagnosed/unsuppressed hiv, increasing their risk for hiv acquisition [29] . the prevention benefits of tasp and u=u can only be extended to ybmsm if these gaps in the hiv care continuum are addressed. similarly, the efficacy of oral daily prep depends on care engagement (i.e., prep uptake), medication adherence, and persistence. both tdf/ftc and taf/ftc have shown themselves to be durable and safe options for hiv prevention, being approved for use in adolescents weighing over 35 kg in 2018 and 2019, respectively. however, similar to tasp, issues with awareness, access, provider knowledge and bias, cost, medical distrust, and low risk perception may adversely impact medical engagement and adherence among aya in general and ybmsm in particular [30] . moreover, consent and confidentiality barriers have plagued widespread acceptance of prep among medical and public health communities who would promote prep use [31] , due in part to concerns about adherence with follow-up visits and long-term effects on bone and kidney health [32] . young msm of all ethnicities demonstrate low levels of knowledge, but high levels of acceptability with regard to prep [33] [34] [35] . prep interest, uptake, and usage are particularly low among ybmsm [36] , even in the settings where they are aware of and able to access prep [37, 38] . multilevel and system barriers to prep access exist in families, communities, and medical spaces. pediatric and other medical providers are often limited in their ability to engage aya in general and sexual and gender minority aya in particular around their sexual health [39] [40] [41] [42] [43] . many are also unaware of or unfamiliar with prep, leading to missed opportunities to discuss sexual health and other prevention strategies with ybmsm who may be at risk [44] . provider bias has also been shown to decrease likelihood to prescribe prep to black msm, based on racialized beliefs that more sexual behavior risk compensation will ensue as a result of prep usage among black msm [45] . as a result, black msm have expressed experiencing heightened prep stigma, leading to distrust that affects agency in both medical decision-making and comfort discussing sexuality and behavior with medical providers [27, 46, 47] . specifically, ybmsm and transgender women who have sex with men (tgwsm) express additional stigma surrounding promiscuity assumptions, cost, and other conspiracy beliefs as deterrents from prep use [48] [49] [50] [51] [52] . for those who do initiate prep, it has been found to be effective and well tolerated among adolescent populations, but adherence with quarterly visits may wane over time, particularly among ybmsm [49, 53] . finally, issues related to adolescent ability to consent for hiv prevention services including prep and confidentiality pose significant barriers to prep uptake among aya, including ybmsm. while no jurisdictions currently prohibit minor adolescents from consenting for prep, few have passed statutes that explicitly allow minor consent [54] . where the legal statute is not clear and is subject to interpretation, adolescent access to prep may be limited. young adults may remain covered on their parents' insurance until age 26, which increases their ability to access care but may create a barrier to hiv prevention, prep, and other sexual health services if confidentiality cannot be maintained. an explanation of benefits (eob) and/or bills for laboratory or clinic visit co-pays may be sent to their parents, leading to unintentional disclosure of sexual activity, identity, hiv status, or specific sexual health services/diagnoses. for ybmsm, this may present particularly challenging additions to seeking health care when compounded by the persistent intersectional oppressive forces of racism and sexual prejudice. behavioral interventions targeting behaviors associated with hiv acquisition were once the cornerstone of hiv prevention. however, in today's increasingly biomedical hiv prevention landscape, behavioral considerations are often linked to biomedical modalities-with outcomes that focus instead on enhancing behaviors surrounding hiv testing, linkage, engagement, and adherence with services. traditional behavioral interventions, such as those designed to promote condom use, improve communication with sex partners, or prevent sexually transmitted infections (stis), still have an important role to play in counseling and supporting ybmsm. in fact, behavioral approaches may be even more important in this population due to logistical, financial, policy, and other barriers to obtaining prep, and thus should not be so easily discarded as an irrelevant prevention option. several behavioral hiv prevention interventions have been developed specifically targeting ybmsm, while others may have included ybmsm in their original study populations without restricting participation to that group [55] . these interventions, generally based in established social-behavioral theories (e.g., social cognitive theory), use strategies such as education, social support, and role-playing to decrease frequency of self-reported condomless anal intercourse [56] , increase hiv knowledge, improve hiv/sti-related communication skills, and change attitudes and intentions around condom use [57] . a limitation of behavioral interventions for hiv prevention-regardless of the targeted behavioral outcomes-has often been insufficient consideration of the social context that influences behavior. indeed, behavioral interventions that have been most effective at achieving sustained outcomes in black msm have incorporated and addressed the social determinants that contribute to hiv inequities and disparities experienced by this population. one notable example is many men, many voices (3mv), which was developed by and for black msm to specifically address the impact of racism, stigma, homophobia, familial, cultural, and religious norms on hiv risk behaviors and sexual relationship dynamics [58, 59] . 3mv is a cdc-designated evidence-based intervention that has also been tested specifically among ybmsm and was found to be effective for decreasing condomless sex acts [60] . black msm, including ybmsm, have a higher likelihood of living in neighborhoods containing various psychosocial stressors (e.g., neighborhood-level poverty, crime, drug use). these neighborhood-and community-level factors are associated with increased condomless sex and hiv risk [61] ; thus, structural approaches to address these more distal social determinants could enhance hiv prevention efforts focused on ybmsm. examples of structural approaches have included improving access to quality housing [62] , policy change (e.g., laws related to hiv criminalization or syringe exchange), and economic empowerment (e.g., microfinance or conditional cash transfer interventions, primarily used with adolescent women in lower-middle income country settings) [63, 64] . currently, no such structural hiv preventions have been developed and/or tested specifically for ybmsm. a summary of recommendations for improving effectiveness of hiv prevention services for ybmsm is included in table 1 . universal opt out hiv testing is a component of routine health care maintenance [65] and is recommended annually for sexually active aya msm in pediatric and adolescent primary care settings [66, 67] . however, in addition to the barriers with provider-patient communication described above, relatively low primary engagement among young men [68] (including ybmsm) suggests a need for increased access to testing in community settings. ybmsm prefer school-based and other community settings where hiv testing services are offered in a nonjudgmental, private, and confidential manner [69, 70] . moreover, accessible, trusted, and frequently engaged community settings may be ideal for hiv testing. school-based health clinics [71] , health department sexual health clinics [72] , community-based organizations [73] [74] [75] , and other community spaces may facilitate more open discussion and disclosure of sexual health practices and concerns over traditional medical settings [76] . community locations may also be more conducive to pairing testing resources with peer educators or other evidence-based education and outreach strategies, serving as conduits to primary care through partnering with pediatric and adolescent providers to provide treatment and comprehensive care linkage [77] . hiv and sexual health outreach and education through community spaces where ybmsm feel welcome and comfortable may also increase uptake of hiv-related information, motivation, and behavioral skills and increase their utilization of community resources for hiv testing services [78] in addition to enhancing selfefficacy for discussing sexual health services with medical providers [14] . research on the specific factors associated with hiv testing in both adolescent and young adult black msm is limited. the persistent racial disparities in hiv incidence and prevalence affecting aya black msm [79] despite higher testing rates warrant investigations that stratify study populations according to age and race/ethnicity to identify factors that influence testing in this priority population. additional analysis is also needed to inform the design of testing strategies that account for unique barriers resulting from the intersection of age, race/ethnicity, and sexuality ybmsm often face [80] . given the current emphasis on biomedical aspects of hiv prevention and the limitations in aya health care settings described above, improvements in clinical and cultural competencies related to sexual health are needed to ensure these settings are equipped to provide hiv prevention and other sexual health services to ybmsm [14] . gaps in care of ybmsm and other sexual and gender minority youth have persisted [81] despite numerous policy statements and guidelines from the american academy of pediatrics (aap) [82, 83] and the society for adolescent health and medicine (sahm) [84] . these gaps endure because clinicians are often not sufficiently trained in how to care for racially diverse and lgbtq youth [42, 43] . to ensure that aya providers are consistently well prepared to provide clinically and culturally competent hiv prevention and sexual health care to ybmsm and other lgbtq youth, appropriate health curricula should be integrated into medical education at undergraduate, graduate, and practice levels. current and emerging prevention modalities can only be effective for a particular priority population when implementation processes are informed by members of that group. hiv prevention efforts targeting ybmsm should be developed and implemented based on the voices, perspectives, and priorities of ybmsm themselves [85] . several models of community-informed practices including engaging priority populations in the development of prevention messages and campaigns [86] , incorporation of youth or community advisory boards to inform clinical programming [87] , and integration of peer or near-peer navigators with shared identity or experiences with ybmsm [88] have demonstrated promising effects. while additional programmatic evaluation is needed to determine how to best tailor and implement hiv prevention modalities to ybmsm populations, existing data provides some important insights on what program components are necessary. for instance, employing a holistic health approach, including attention to general wellness, mental health, and substance use as well as youth priorities essential to developmental tasks of adolescents (e.g., achieving education and employment goals, housing, navigating and exploring sexuality [89] , developing healthy romantic and intimate relationships) can serve as a gateway to engaging youth in hiv prevention. holistic approaches with frequent follow-up have been found to be successful in ensuring sustained adherence with prep among ybmsm and should be replicated widely [90] . consideration and appreciation for the unique intersecting identities and experiences of ybmsm is also critical. multileveled approaches that consider larger social/structural issues offer the best way to approach prep specifically, but few programs have fully embraced this reality [26, 89] . a sample of ybmsm ages 18 to 24 stated that family and friends, formal education, television, and the lgbtq community were major sources for hiv prevention information [91] . however, motivation for adopting such information was hampered by apathy, homophobia, and racism. emphasizing the understanding and deconstruction of more proximal social contexts like the desire to embody traditional masculine ideologies [92] could hold the key to more holistic sexual health efforts that umbrella education, interest, and eventual uptake of prep. religion often represents a deterrent to sexual health and hiv prevention due to documented homophobia and sexual prejudice within varied black faith communities [46, 75] . however, emphasizing affirming aspects of religion/ spirituality and their relationship to health access and beliefs, sexual health, and perceived risk for hiv may offer avenues for future exploration [76, 77] . sex work, whether chosen or in the context of food and housing insecurity, is a lived experience not unique to ybmsm, but represents an often-ignored circumstance deserving of consideration within our hiv prevention efforts. finally, leveraging the role of chosen nonbiological families, houses, and other nonheteronormative communities will be key in reaching and addressing the sexual health and hiv prevention needs of ybmsm, many who may suffer displacement from their biological families because of their sexual orientation [78] . medical spaces should also offer a menu of services, both in tailored approaches to hiv prevention (behavioral, biomedical, both) and how it would be best to deliver said servicestraditional brick and mortar approach with scheduled appointment, telehealth consultations, home visits and delivery of meds, or some combination of any of these. moreover, embracing technology in behavioral and biomedical hiv prevention approaches in the form of apps, telemedicine, and other unique interventions is a requirement for youth-based populations [55, 93 •• , 94] . as intergenerational differences may deter communication and uptake of hiv prevention services, it is crucial to ensure that an adequate representation of youth is present for hiv prevention navigation (tasp and prep), and that younger medical staff beyond the medical providers themselves are actively engaged and involved in patient care [95] . a team approach that emphasizes a collaborative and familial environment can provide aya, specifically ybmsm, with the guidance they need to navigate a complicated medical system that is challenging even for adults. the society for adolescent health and medicine recently published a position paper on improving prep access for adolescents and young adults that highlighted three of the most significant policy and structural barriers to aya prep engagement [96 •• ] . first, aya representation in clinical trial research at each stage of prep continuum is limited due to complexities of engaging adolescent minors in research. second, whether adolescents under 18 can consent to prep care is unclear in most jurisdictions and confidentiality issues for aya covered under insurance plans where their parents are the primary policyholders are largely unresolved. third, there is limited financial assistance for expenses beyond prescription costs such as monitoring labs, sti/hiv testing, clinic visits, and other related expenses. these are important gaps for ybmsm and represent policy considerations to consider when tailoring hiv prevention tools to this priority population. we cannot identify what approaches will work for at-risk populations if they are not included in research [97] . while engaging minor adolescents in sexual health research is complex and requires protections be put in place to ensure their safety, there is a growing body of evidence supporting that adolescents can freely consent to research, including research concerning sexual health and hiv prevention [98] [99] [100] . requiring parental permission represents a unique barrier for ybmsm and other lgbtq youth who may not have disclosed their identity or sexual behavior to their parents or otherwise lack parental support. youth have reported being unwilling to participate in hiv-related research that requires parental permission [99, 101, 102] , and parents have also acknowledged that requiring permission can place youth who are not "out" at risk [103] . adolescents do, however, represent a vulnerable population in need of added research protections such as the inclusion of a peer advocate, a strategy that has been endorsed by lgbtq youth [99] . researchers have also called for the inclusion of structured time for youth to reevaluate their decision to participate in a study [104] . youth may also need to be provided with additional information about randomization when participating in trials, and researchers must ensure they understand the distinction between participating in a research project and receiving personalized medical care [101] . finally, the inclusion of youth who have yet to invite their families into their sexual orientation/gender identity requires extra privacy considerations at all stages of research. recruitment or study materials that mention their sexual identities or behaviors may lead to unintentional disclosures if materials are seen by relatives or peers, as may study activities that occur at locations associated with lgbt communities [104] . minor consent laws are decided in states and local jurisdiction, so local hiv, lgbtq and youth advocates, chapters of professional medical and civic associations, and communities should advocate for changes in minor consent laws that will allow adolescents to consent for hiv prevention services, particularly prep. as delivery options for prep continue to expand, ensuring that minor ybmsm can access the full array of hiv prevention options without parental consent will be critical. similarly, for youth covered by their parents' insurance, developing protocols that ensure confidentiality in the nature of sexual health and hiv prevention lab testing is critical. ybmsm must feel comfortable accessing services, knowing that an eob will not disclose their sexual behavior, lab tests, or hiv status to their parents. current policies often require the covered individual to contact their insurer to request changes in either the details provided on the eob or where this information is sent, a process that can be difficult to navigate for many ybmsm and most aya. while patient assistance programs have eased the financial burden for accessing both art and prep medications, ybmsm may still be burdened with the cost of follow-up visits and lab testing. there are several potential sources for financial assistance for these additional costs. some states have developed prep assistance programs to assist with these costs for those at risk for hiv acquisition [105] . both insurance plans and patient assistance programs including those sponsored by pharmaceutical companies should also be approached to include provisions that ensure basic lab services and follow-up visits will be covered, as continued costs for these services serve as a deterrent for ybmsm to stay engaged in care and adherent to medications. ybmsm are at increased susceptibility to hiv partly due to exposure to sexual networks with undiagnosed/unsuppressed hiv and untreated stis that facilitate hiv transmission [106] [107] [108] [109] [110] [111] [112] [113] . interrupting this cycle requires public health diagnosis, prevention, and treatment strategies that prioritize (1) identifying hiv transmission networks; (2) accessing and identifying individuals within these networks; and (3) linking these individuals to effective hiv prevention or treatment options. innovative strategies for identifying transmission networks and individuals within these networks not currently linked to prevention or treatment are needed to reduce hiv risk for ybmsm in these networks. behavioral approaches that focus on prep or art adherence are an important consideration for ensuring effective implementation of biomedical prevention strategies. however, it is also important to consider that prep medications are "indicated in combination with safer sex practices," [115] making the sexual behavioral targets of traditional hiv behavioral interventions continually relevant and important. furthermore, given the challenges with heightened risk and effective implementation of tasp and prep among ybmsm, nonjudgmental behavioral approaches that focus on effective risk mitigation may have even greater importance. whatever the behavioral target, behavioral interventions should also address complexities ybmsm face at the intersection of race, sexuality, and development, with reinforcement of affirming approaches to sexual health that acknowledge and target racial and sexual identification [58, 116] . addressing the distal social determinants of health and the syndemics that contribute to hiv inequities impacting ybmsm are important targets for structural interventions, but have not been explicitly explored in this population. as these inequities persist, the urgency of ongoing hiv burden demands trials of innovative strategies that have been effective in other populations or settings. in addition to what has been previously mentioned, from a societal perspective, we must acknowledge how the pervasive distal scourge of racism relates to hiv prevention, with medical and public health systems working on eradicating discrimination within medical spaces and acknowledging the impact of racism on health inequities among ybmsm [117] . highlighting the intersection of racial and sexual identities is paramount as we know that embracing both is key to wellness among ybmsm [118] . initiatives should also emphasize the roles that gender norms and religious doctrines/beliefs play in the overall health and lived experiences of ybmsm [92, 119] [27, 120] [121, 122]. perhaps most critical for our consideration of distal forces influencing evolving hiv prevention efforts is our framing of sexuality among black men itself, specifically, what sexuality and intimacy means beyond the over-biomedicalized, analytical, and often pathological defining of sexual acts as just sexual networking, condomless sex, and risk for hiv and stis. future hiv prevention models targeting ybmsm should reflect a more contemporary conception of same gender love, intimacy, and pleasure between black men that acknowledges how physical and sexual acts serve as vehicles of emotional connectedness in defiance of lived experiences with racism, sexual prejudice, and other social forces. they are not simply "risky encounters" that require immediate hiv testing, daily pills, or bimonthly injections. creating affirming and nonjudgmental approaches within physical/virtual spaces that reflect these realities for ybmsm is crucial in this equation. effective hiv prevention options have expanded significantly, creating the tools necessary to end the hiv epidemic. ensuring equitable and tailored access to ybmsm is the challenge that lies in front of us. more research and interventions are needed that specifically focus on ybmsm communities. improving medical systems and provider attitudes will be invaluable to enhance clinical spaces that often judge and stigmatize them for simply being who they are. 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racism on child and adolescent health racial and sexual identities as potential buffers to risky sexual behavior for black gay and bisexual emerging adult men the relationship between gender role conflict and condom use among black msm key: cord-307753-p1htdvrp authors: haldon, john; eisenberg, merle; mordechai, lee; izdebski, adam; white, sam title: lessons from the past, policies for the future: resilience and sustainability in past crises date: 2020-05-24 journal: environ syst decis doi: 10.1007/s10669-020-09778-9 sha: doc_id: 307753 cord_uid: p1htdvrp this article surveys some examples of the ways past societies have responded to environmental stressors such as famine, war, and pandemic. we show that people in the past did think about system recovery, but only on a sectoral scale. they did perceive challenges and respond appropriately, but within cultural constraints and resource limitations. risk mitigation was generally limited in scope, localized, and again determined by cultural logic that may not necessarily have been aware of more than symptoms, rather than actual causes. we also show that risk-managing and risk-mitigating arrangements often favored the vested interests of elites rather than the population more widely, an issue policy makers today still face. effective risk management and assessment require knowledge of past events to generate comparative risk scenarios. yet understanding the impacts of environmental stress on historical societies is an underdeveloped and fragmented field of study, with substantial disagreement among specialists. as a result, we cannot say with precision what constitutes an existential risk to a given historical society, i.e., a risk that could trigger the collapse of a political or cultural system. past human societies as a whole have been extraordinarily resilient in the face of severe challenges, but the configuration of social and political structures was always impacted in a number of ways, with substantial implications for development pathways (e.g., the different medium-term outcomes of the black death in england and france) (borsch 2005, pp. 55-66; herlihy 1997) . historical case studies, therefore, can offer valuable guidance on present day issues in designing risk management strategies and sustainable policies (haldon and rosen 2018; rosen 2007) . detailed research into what, if any, role environmental challenges have played in the transformation of previous societies, including in conflict, migration, critical systems failure, and politics, is an essential requirement, along with grounded inquiry into socio-economic feedback loops. the study of complex historical societies can reveal how such challenges worked to transform structural relationships and daily life. but it can also tell us about what happened when the dust settled and how both leaders and governments and the members of society more broadly re-evaluated their situations. there are several key questions that historical case studies reveal. did people in the more distant past think about system recovery? we show that this depends significantly on system structure and capacity, nuanced and constrained by ideological assumptions. contemporaries perceived the scope of recovery within a state as a goal, but were focused on their own institutions, while considering recovery at a global scale was rare and conceptualized and promoted generally within the purview of religion. were people aware and did they respond, negatively or positively, to changes in their (perceived) social situation, impacts on the economy and finance, on beliefs and attitudes? the answers reflect different historically specific understandings * john haldon jhaldon@princeton.edu of a situation, both the type of society as well as their social status. moreover, in the pre-modern/pre-scientific world, moral and religious responses were as important as practical responses. did rulers and elites, or farmers and producers, implement policies that would mitigate risk and absorb future shocks? we suggest how some past societies, ranging from the later roman period down to the early modern world, responded, consciously or less so, to transformative and unpredictable environmental pressures. one common thread of these historical examples is a tendency of system recoveries to focus on elite-level actors, rather than all levels of society that were more numerous. however, as some of these cases demonstrate, a more just and equitable resiliency can lead to longer-term stability for the state and its institutions. how societies in the past responded to stress depends on three key sets of conditions: their complexity (the degree of interdependency across social relationships and structures), their institutional and ideological flexibility, and their systemic redundancy, all of which together determine the resilience of the system. these three conditions do not exist in isolation, but combine and recombine in innumerable historical configurations. historians must reduce this to ideal-typical models, since it is practically impossible to analyze them all. moreover, we must research particular historical case studies to illustrate these general patterns and to show how each case is subtly different from the next. 'resilience' is invoked in different ways within different disciplines. in historical research, it has largely played a role in work on collapse and adaptation, where societies are understood as complex adaptive systems and in which ecological models have been influential. since the basic structural dynamics of a societal system contribute to the types of collapse to which it may be subject, approaches to collapse, and resilience that unites structure and process are the best way forward in applying historical examples to contemporary planning initiatives with respect to environmental problems. this is a helpful approach, especially when allowances are made for individual human agency and belief systems (cumming and petersen 2017; haldon 2020 , building on ecological theory and formal resilience theory; also anderies 2006; berkes and ross 2016; gunderson and holling 2002) . resilience and the potential for a society to maintain cohesion and cultural continuity through periods of systemchallenging stress has costs. the question of how to distribute the costs of resilience, and the degree to which this might be built into any system, varies across time and cultural milieu. in the following, we examine several cases in past societies where we can observe (1) both top-down and bottom-up responses to significant environmental challenges, how different sectors of society responded or reacted, and where we can detect positive as well as negative outcomes; (2) the differential costs of resilience when states are faced with substantial economic and political challenges; and (3) state-and society-level responses to pandemics and both planned and unintended consequences. 2 pandemics: responses, resilience, and consequences by the year 500, the western roman empire had disappeared as a cohesive political state across western europe, but the eastern roman empire simultaneously flourished. the western half had divided into successor "barbarian" kingdoms, while the eastern roman empire was centered around the balkans, anatolia (mod. turkey), and the middle east. one of its main initiatives, the re-conquest of formerly roman regions in the west, such as north africa and italy, had begun well-with quick and cheap conquests. at the height of this re-conquest in the early 540 s, the justinianic plague erupted across the mediterreanean world and europe. the justinianic plague was a pandemic of the bacterium yersinia pestis that remained active for over two centuries, c. 541-750 c.e. its impact on the eurasian population has been suggested as significant (i.e., causing the deaths of tens of millions), while its effects on human behavior from economics to culture and religion have also been described as pivotal (meier 2016; harper 2017; sarris 2006) . some have described it as the watershed moment separating a flourishing ancient world from the darker medieval world. while this master narrative is deeply problematic and has been challenged in recent years, individual outbreaks-the local impact of the plague during that two-century frameworkhave been entirely ignored ). the problematic 'catastrophe' narrative is simply copied and pasted across all of its outbreaks (sarris 2002 (sarris , 2011 ). yet if we examine particular outbreaks, even the destructive demographic narrative demonstrates the ability of the eastern roman state to react both immediately to the increased numbers of deaths, maintain vital administrative efforts, and continue its long-term political goals. the contemporary writers procopius of caesarea and john of ephesus recorded intricate details about the first outbreak in the city of constantinople in 542 c.e. the number of deaths was significant, especially given the city's urban density, but hard numbers or even percentages are completely uncertain. procopius wrote that the outbreak lasted for three particularly virulent months and claimed that 5000 and then 10,000 people died per day. using these numbers, the number of deaths would have reached 675,000 by the end of the three months, while the population of constantinople was perhaps around 500,000, so these numbers are impossible (procopius, wars 1914, ii. xxii-xxxiii) . john of ephesus included even higher numbers, up to 16,000 deaths per day (john of ephesus). some modern scholars have suggested that 20% of the city's population died and more recently that 50% died, although these percentages are conjectures based on dubious assumptions (bratton 1981; stathakopoulos 2004; harper 2017) . recent attempts to use epidemiological modeling could not resolve this problematic question (white and mordechai 2020) . while sixth century romans would not have understood modern epidemiology, there are examples of self-isolation to stop the spread of plague. procopius recounts that many people who had the economic means locked themselves into their houses as a way to avoid infection. sometimes this attempt backfired, since entire houses would perish from plague and the dead would remain unburied for days (procopius, wars 1914, ii. xxii-xxxiii) . during later outbreaks of plague in constantinople, elites, including the emperor himself, fled to nearby urban centers, while in other cases an entire city fled the arrival of the plague, decamping into the mountains (theophanes confessor, chronographia, am 6053; paul the deacon, history of the lombards 1878, 4.14). in total, romans understood that the plague was an unexpected new phenomenon and adapted accordingly by trying to mitigate its spread. these lessons of how to prevent the spread of plague also suggest that people around the mediterranean world not only tolerated disruptions to their socio-economic activity, but even embraced them in some cases-preferring flight over simple isolation. despite the limited information at their disposal, communities and individuals attempted to weather the storm using whatever means were at their disposal. as twentieth century disease outbreaks suggest, even a much smaller percentage increase in deaths per day can quickly overwhelm the existing capacity of a modern state to bury its dead (crosby 2003; kilgannon 2020) . the imperial administration and the emperor justinian (r. 527-565), who took a personal hand in directing the response, recognized the overwhelming burial problem and responded quickly by appointing an administrator named theodorus to solve it. theodorus received money to hire people to help bury the poorer members of society, whose families could not afford or arrange for their burial. initially, they were placed in existing cemeteries, but as these filled up, theodorus' task force dug new larger trenches and pits to place the large numbers of bodies, a scene reminiscent of current day burials. theodorus, and by extension the state itself, could clearly adapt to different burial requirements both culturally and logistically as the situation required it. unlike in many cases today, the various political factions stopped their fighting and helped provide the manpower for theodorus to meet his grim new task (procopius). despite the significant mortality, these burial measures resolved the most pressing issue for constantinople: removing dead bodies to ensure other infections did not spread. the pandemic appears to have reached the rest of the mediterranean from egypt, where it arrived perhaps via the red sea and the indian ocean trade from central asia. from egypt, it reached constantinople through the regular grain shipments the city required to sustain its population. other port cities around the eastern mediterranean were struck soon afterwards (procopius). in the first few years after the outbreak in 542, the grain shipments from egypt appear to have been reduced due to some combination of a smaller population that required less food and the disruption of trade routes due to the pandemic. yet within five years the grain shipments had returned to their original quantity demonstrating that the state had bounced back and was able to provide resources as it had before the outbreak (zuckerman 2004) . in both of these short-term solutions, the state was remarkably flexible in its approaches to quickly meet an entirely new problem with limited resources at hand. most of the eastern roman budget was used to pay the army, with a smaller amount for the salaries of administrators (hendy 1985, 157ff.). the roman government was able to quickly shift resources, establish an entirely new ad hoc administrative section, and ensure the continued flow of food to constantinople to prevent large-scale famine despite a significant epidemic outbreak. the short-term flexibility depended on systemic capabilities developed and maintained over centuries, which had long incorporated significant fluctuations to the supply of goods (rickman 1980). for instance, procurement of grain in egypt was likely a highly planned and regulated practice that had been operating for almost six centuries. both the government in constantinople and local officials in egypt prioritized grain procurement as a core systemic function. the grain shipments had significant built-in redundancies that would guarantee that enough grain reached constantinople despite unexpected (but known and relatively common) dangers such as shipwrecks, spoiled food, and unfavorable sailing weather slowing shipments. administrators often had significant experience in their positions adapting to these known problems and likely passed much of this to their replacements. this approach allowed the system to mitigate disruptions such as the outbreak of plague. however, major political disruptions such as the conquest of egypt by the persians several decades later had a far more significant result-the abrupt ending of all shipments from egyptwhich forced the government to scramble to search for new grain-supplying regions (haldon 2016) . despite the immediate disruption of plague, the eastern roman state was able to continue its existing military, political, and administrative goals. justinian's re-conquest of italy proceeded in slow, halting steps and was completed within a little over a decade; italy was then integrated back into the eastern roman state (heather 2018) . in the east, the status quo in the conflict with the persian empire was largely maintained and the roman state continued spending vast sums on the military for the next half century. taxes and resources continued to flow freely to the state with no evidence of plague-related problems (sarris 2006) . part of this was due, in all probability, to the redundancies built into the imperial system itself as in the case of the grain supply noted above. the late roman system was, by modern standards, inefficient and did not prioritize the market gains at every level or create massive, intricate supply lines. instead, it prioritized flexibility in using governmental resources, while assuming most needs would be met locally, a system that also generated duplication of activity in various administrative departments both centrally and in the provinces. within these constraints, and in part as a direct result of them, the roman state appears to have had little trouble returning to its baseline requirements even amidst the most significant epidemic to yet strike the known world. it is impossible to discern what the immediate demographic (let alone cultural, economic, and social) impact of this plague outbreak was. what is clear, however, is that the state weathered the storm through short-term efforts to protect the population of constantinople, while the populace itself created their own measures to prevent the spread of plague. while commerce and food supplies might have been stressed during the immediate outbreak, contemporary historians do not report on foot shortages; regardless, both of these returned to their pre-outbreak levels within just a few years. the outbreak did not change long-term political goals, the state's ability to fight wars, or raise taxes, and move resources around, and unlike other examples in this paper, there was no discernible change in power structures and elite-lower class labor relations. in fact, the plague outbreak seems not to have catalyzed any significant changes in the way the east roman state was managed. its demographic impact may have produced short-term shock waves across constantinople (and probably other parts of the empire about which we are less well-informed), but it hardly transformed the shape of the world or even the empire. a much better-known case of plague is the notorious black death of 1346-1352, the second of the three pandemics of yersinia pestis that have impacted the world since the late ancient period (the third was a global pandemic from c. . claims of mortality rates of as much as 50% give the impression that this event must have been devastating for the societies affected. yet when we examine how different states and societies responded, we find that-without minimizing the terrible impact on people and communities-the medieval world did not grind to a halt, still less did a series of revolutionary transformations occur. indeed, the black death struck at the beginning of the hundred years' war, and in spite of its demographic impact both the kingdoms of england and france continued to field effective armies, even if there was a brief pause in hostilities (similar to contemporary calls for ceasefires in ongoing international conflicts in the context of covid-19). instead, some societal developments that were already under way accelerated while various groups within society responded by exploiting their situation and attempting to slow down, stop or otherwise control changes which they perceived as disadvantageous. the arrival of the black death in 1348 is sometimes associated with the eventual breakdown of 'feudalism' and the rise of capitalism, as the plague's high mortality and consequent shortage of labor was supposed to have dramatically changed the way the labor market was structured. in short, it is said to have challenged existing landlord-tenant relationships and the whole basis of serfdom (the legal binding of peasants to the lands of elites). yet in england serfdom was already declining by the time of the black death (hilton 1985, pp. 55-58; campbell 2005) . moreover, landlords can respond to labor shortages in various ways-in eastern europe, for example, they increasingly tied labor to the land and imposed a more oppressive serfdom on the peasantry. from the later twelfth century on, reflecting elite demand in respect of consumption and increased expenditures, and backed by royal legislation, landlords in england demanded heavier labor services, reducing peasant holdings and thus the ability of the serfs to do anything more than maintain a bare subsistence. this last tendency was intensified, again with the backing of the state, in further repression of peasants' rights and freedoms following the demographic collapse caused by the pandemic. yet a trend toward labor shortages and demographic changes had set in well before this, following the so-called great famine (1315-1317). in this context, the black death was less a prime cause than a further exacerbating and intensifying factor (britnell 2004, pp. 368-387; cohn 2007; whittle 2007; postan 1973; hilton 1973 hilton /2003 hilton , 1975 . the black death and the accompanying increased pace of demographic contraction did not in themselves, therefore, lead either to the end or to an intensification of servile relationships. rather, a number of regionally nuanced factors played a role, among which one of the most important was the degree of class difference. as wealthier peasants resisted labor services, the poorer members of their communities could be employed-and exploited-as wage earners. indeed, one answer to the lords' demands for greater cash liquidity was the leasing of their estate land to wealthier peasant tenants. where this occurred the demand for wagelabor among the lessees of lords' estate lands rose, thus stimulating a clearer rural social hierarchy (britnell 2004, pp. 429-450, esp. 432-433) . the internal social structure of peasant communities was the key determining element. the contours of rural and urban society in england shifted considerably between the later twelfth and later fifteenth centuries, but no single factor was the cause. a reassessment of the black death reveals that its diverse indirect consequences were perhaps more important than the immediate, felt and visible impacts as reported by eyewitnesses, that tend to draw our attention. as such, the black death played an important role in accelerating existing trends, pushing some-but over several decades-beyond a threshold that then led to substantial change. when thinking about similar moments in the past or the present, it is the impact on the underlying structures of social and economic organization to which we need to pay attention. government intervention to address problems perceived from the center often fail to adequately take into account the range and complexity of causes underlying the issue addressed in state action. the ottoman empire from the late sixteenth to early seventeenth centuries ce provides a good illustration of the limits to resilience in a pre-industrial society. beginning from a small emirate in northwest anatolia ca. 1300 ce, ottoman rulers had by the 1550s expanded their territory to three continents covering 30 present day countries and built an empire that drew on administratively and geographically diverse sources of income. a key factor in the empire's resilience was thus its size. it developed systems to mobilize crucial resources from distant locations to provision its cities and military and to balance regional surpluses and deficits, including food, labor, timber, and strategic materials (e.g., gunpowder). the security provided by ottoman soldiers as well as legal and tax provisions encouraged the expansion of agriculture and the containment of mobile pastoralism. the empire seemed resilient to socio-environmental stress: when tested by a series of local droughts, shortages and famines during the 1560s-1580s, ottoman officials were able to contain the damage by shifting tax burdens from the affected areas, ordering fixedprice sales of grain from other provinces, and in some cases arranging direct shipments from local or imperial granaries (white 2011; mikhail 2011; agoston 2004 ). the ottoman system of resource management could recover from small impacts, but multiple, continuous or repeated shocks pushed it towards breakdown, a situation that underlies the scale of crisis in the empire during the 1590s-1600 s. this was a period of major crisis triggered by environmental and human stressors followed by a protracted and intermittent recovery, in terms of population, agricultural production, political stability and military power. extended drought in central anatolia in 1591-1596 severely curtailed food output causing prices to double. near-famine conditions developed in some regions. this coincided with a series of extraordinarily cold winters, a combination that caused a major epizootic outbreak affecting sheep and cattle across anatolia, the crimea, and the balkans, eventually reaching hungary and central europe. this massive death of livestock deprived rural producers of a major source of wealth and subsistence, and deprived ottoman armies of a key source of protein (white 2017 with detail and sources). this was not, however, the only set of stress factors the empire faced, since it was at this time deeply enmeshed in the so-called long war (1593-1607) with the habsburg empire. therefore, instead of reducing taxation or providing relief supplies-the usual state response to droughts and famines-the state had to increase requisitions from the balkan and anatolian provinces that were the worst hit by escalating shortages and famines. this led to a major rural uprising, the so-called celã¢lã® rebellion (1596-1610) (white 2011) . the combination of famine, violence, population displacement and disease generated a significant mortality crisis in parts of the empire-tax records from the 1620s-1640s suggest up to 50% mortality in many parts of anatolia after the 1580s (ã�zel 2004, 2016 )-all of which produced a situation that induced a long-term shift in ottoman population and land use (ã�zel 2016 ; white 2011 and sources therein; ocakoä�lu et al. 2016) . the history of the late 1500s-early 1600s is a good illustration of how political complexity could constrain resilience in a situation where a combination of factors amplified the negative consequences of state activities, in this case a focus on revenue, provisioning, and military mobilization at the expense of diversification and risk reduction in during environmental stress. lack of agricultural diversification in semi-arid regions, dependence on provinces near the imperial capital for extraordinary taxes and requisitions, lack of spare capacity in dealing with both simultaneous military and infrastructural emergencies, all stressed the system to capacity. these factors combined with difficulties of supplying and pacifying inland regions, poor overland communications and the interaction of famine, flight, insecurity, and disease. together with inadequate public health systems that might mitigate epidemic disease impacts, the result was a severe and sustained population loss leading to an unstable balance between village agriculture and mobile pastoralism-and ultimately a fracturing of state management and control over provincial economies. while the imperial system as a whole held together, the cost of the vulnerabilities inherent in the ottoman system were borne disproportionately by the least privileged social groups. just as in a markedly different context with the eastern roman empire (the case discussed below), this potentially undermined the resilience of the entire socioeconomic and political system, since these groups formed the backbone of pre-modern economies. while these groups possessed a remarkable degree of resilience within the limits imposed by environmental and political conditions, when both acute social and environmental problems combined they could neither sustain their own livelihoods nor shoulder the burdens of imperial economies and ecologies. the role of elites and particular groups in social classes are central to the resilience of 'states' themselves. historically 'states' have tended to be dominated-managed and administered-by members of a power-elite drawn from a socially privileged sector of society. members of such groups are generally concerned as much with their own interests as they are with those of the state or ruler they serve, although some pre-modern states have been able to maintain, for a while, an establishment entirely divorced from the vested interests of their society. the eastern roman empire was undoubtedly one of the most sophisticated states in western eurasia, with a complex and effective fiscal and administrative structure that maximized resource extraction and maintained a balance of power between the state, elites and provincial society. by the early tenth century, after two centuries of rebuilding following the shock of the early islamic conquests, it was entering a period of expansion in both the balkans and the middle east. in parallel, there had evolved a social elite of office holders and landowners who gradually achieved a near monopoly on the senior and middling posts in the military and civil administration. it was their task to implement government policy in the provinces, but their increasing wealth and status meant that by the tenth century they were also a potential source of opposition to the central government. the tension between these two aspects of the east roman state revealed itself in the efforts of the elite to expand its wealth in land, generally at the expense of village communities who were a key element in the state's finances and provided the core of the provincial armies, thus jeopardizing the effectiveness of the central state administration itself. it should be noted that this is a structural problem common to all pre-modern/pre-capitalist systems: states must rely on elites to maintain themselves, yet those elites, whatever their origins, also develop vested interests that compromise or jeopardize those of the state. the ways this relationship has worked itself out historically varied enormously. the problem remains today, of course, although 'elites' are generally both more complexly structured and sectorized (national, international and multinational), and state autonomy-and thus state economies-compromised by global economic factors: the interests of international finance and investment capital rarely overlap neatly with those of nation states, as variations in the markets, particularly during moments of global crisis, daily illustrate. in the 920s a series of natural disasters disastrously impacted the agriculture of the western anatolian provinces, giving the wealthy or powerful opportunities to absorb further properties into their estates (kaplan 1992; svoronos 1994; mcgeer 2000; morris 1976 ). in 927-928 ce there occurred a particularly severe winter in the balkans and anatolia, combined with a series of extremely poor reduced harvests. the result was later remembered (just as was the similarly disastrous famine that preceded the black death in europe) as the 'great famine'. in their description of the resulting social crisis, legal sources distinguish between the 'powerful' (military and civil officials paid in gold coin by the central government and possessing liquid assets) and the 'weak' (peasant farmers and laborers whose livelihood and ability to pay their taxes depended on their harvest). the latter were forced into selling their land for food or money to survive. it is not surprising, therefore, that a subsistence crisis provided those with the necessary resources an opportunity to exchange liquid assets for large tracts of land. to protect its own interests the state had to intervene through legislation that attempted to stop this increased inequality. however, the legislation the state promulgated to try to deal with the issue ultimately had only short-term success, chiefly because the people it depended on to implement these laws were themselves the people against whom the legislation was directed. instead, the government was eventually forced to adopt the tactics of the elite, converting public land into imperial estates in order to secure the income derived from them. the great famine of 927-928 did not create social change but did accelerate it. its impact was twofold. it presented the better-off with an opportunity to exploit peasants whose livelihood had been destabilized by the severity of the winter. the state reacted by guaranteeing its survival by effectively seizing control itself of the private land of the free peasantry, who thus found themselves reduced to dependency either by the state that should have protected them or by those who sought to dispossess them. in the state's attempt to restrain its own elites, it destroyed the fortunes of the more vulnerable members of society. antioch (today antakya, turkey) in the northeastern corner of the mediterranean, was perhaps the third largest city in the flourishing sixth century eastern roman empire. as an administrative center, it connected the empire's heartlands in the s. balkans and nw. anatolia to its wealthy province of syria. antioch was also an economic and cultural powerhouse, serving as a major node in the network of eastern mediterranean cities and boasting rare amenities for the time (e.g., night lighting), a religious hub (e.g., it was one of the five key centers of christianity), as well as a major economic node in the dense network of eastern mediterranean cities. over the sixth century, antioch suffered a series of major disasters that included at least six destructive earthquakes, a major fire, a foreign sack and several smaller raids, the deportation of many of its citizens to a foreign country, and at least four outbreaks of plague. yet, antioch survived these disasters and remained a major regional center. since antioch could not be allowed to collapse for the political, ideological and administrative reasons summarized above, the central government at constantinople ensured its survival by providing it with constant infusions of resources. these included tax remittances, outside workers and resources for reconstruction after each major disaster, and even an extensive imperial initiative to remodel the city (procopius, buildings 1914, 2.10). the government complemented its material efforts with public relations campaigns to lure immigrants to antioch. it employed propaganda, such as changing the city's name to theoupolis, literally "the city of god", used in official communications and on newly minted coins. the government instituted additional popular measures such as free food rations, bringing in grain from egypt to the city where it was baked and handed out (part of the same institution that supplied constantinople with grain, discussed above). such practices served to maintain antioch's population by attracting poor and refugees from the greater region and keeping those destitute from the recent disasters in the city. from the perspective of the central government, these actions were successful in maintaining antioch's position, its primary objective in the region. its actions, however, had indirect consequences. although specific economic costs are unknown, the governmental support of antioch was a decades-long process that strained the central government, forcing it to reduce the amount of resources available for other central initiatives such as its foreign policy (e.g., wars in italy). at the same time, drawing immigrants to antioch weakened social cohesion in the city. frequent riots among different groups within the city occurred, frequently based on religious or other markers of difference. the government's pumping of money into antioch had other unintended consequences. the city was part of several trade networks, importing goods from across the mediterranean, such as north african pottery, and exporting them to the inland syrian cities. at the same time, it exported its own local goods, such as olive oil, across the mediterranean. this oil was produced in antioch's hinterland. the disruption of these economic networks damaged antioch's commercial relationships and crashed the local economy, worsening the economic condition of the residents of antioch's hinterland and likely establishing a feedback loop that further encouraged migration to the city. the former trend of rural economic expansion stopped, and although antioch slowly re-established its inter-regional connections, its local olive oil industry never recovered (mordechai 2018) . whether governmental policy on antioch could resolve these more complex stresses remains unknown. a decade into the seventh century, antioch was lost temporarily to a persian attack and then permanently to islamic conquest. such regional disruptions prevent us from assessing the longer-term results of the imperial government's policies on antioch. although the causes and even the process of the islamic conquest remain unclear and debated, the disruption wrought by the sixth century disasters and the imperial response likely contributed to the eastern provinces' vulnerability over the longer term. a second case study from the same period reveals a different story with the participation of the central government. the history of the eastern regions of the later roman empire in the fifth-seventh centuries ce offers a good example of how one sector within a social system lost even as society as a whole benefitted. between 470 ce and lasting until ca. 670/720 ce (izdebski et al. 2016) , climate change led to increased winter precipitation that enabled a profound transformation in late antique society. the increased winter rainfall, crucial for cereal cultivation in most of the eastern mediterranean, shifted the ecological frontier between arid areas and the land suitable for cereal cultivation. although the introduction of farming on these marginal lands often required sophisticated irrigation and water-harvesting techniques (in the negev desert, for example), the changing climate permitted an extension of agricultural production into regions previously left uncultivated or used only as pastures. eastern roman society was remarkably efficient at turning the environmental challenge of increased precipitation into an economic opportunity, and several regions saw an unprecedented expansion of agriculture and rural settlement (izdebski et al. 2016) . this increase in agricultural production in turn encouraged contemporaries to specialize in cash crops, such as olives and vine, visible in a number of microregions across the eastern mediterranean (see for instance england et al. 2008; varinlioä�lu 2011; izdebski 2013a, b) . however, this climate-related economic growth also contributed to a shift in the balance of control over resources between urban and rural populations in anatolia and the levant. in the late fifth and sixth centuries, new agricultural regions had fewer cities, while large villages dominated as opposed to densely populated urban centers. although the dramatic expansion into marginal lands occurred on the fringes of urbanized regions, new settlements encroached on lands that were located beyond the traditional hinterlands of existing urban communities, and escaped their political and economic control (e.g., niewã¶hner 2006) . this inaugurated a decline in the political and cultural role of many cities, contributing to an ongoing transformation of economic relationships between town and country, and elites and the producing population (brandes and haldon 2000) . climate changes allowed rural populations to accelerate this process and become more independent from cities while at the same time leading to a more general urban decline. here we see a situation in which different social groups depend on various ecological niches. environmental stress led to varying consequences for each of them, leading to a renegotiation of economic relationships and to changes in the balance of power. in the late roman world, urban populations were relatively privileged, both in their access to local resources and the state support they often received. in theory, therefore, they should have fared better through greater access to resources. but their position was actually undermined by what would generally be understood as a beneficial environmental change: their control and dominance over rural populations diminished as a result of the expansion of rural settlement onto new agricultural land, made possible to a large extent by a shift in precipitation patterns. a number of conclusions or lessons can be drawn from these examples, all of which involved states or societies that were complex, possessed institutional and ideological flexibility, and a degree of systemic redundancy, which is to say, overlapping institutional arrangements that in many instances could permit elements of one facet of social organization or state structure to fail without jeopardizing the system as a whole. first, the costs of resilience have never been shared evenly among the different components of complex social systems. political complexity has always had advantages and disadvantages in maintaining resilience in the face of environmental stress. resilience in one social group or institution-the rapid return of its baseline function, lifestyle and living conditions-influenced other groups within the same society. but to understand the potential for all groups to receive just returns we need to understand the connections between different social groups and their environments. the underprivileged or less powerful have always been the most likely to bear the costs of societal resilience to environmental stress. the examples also illustrate the point that even where efforts were made consciously to assist a whole community-for example, in the case of sixth century antioch-the outcome could often generate unpredictable changes that could impact that community negatively. not only do shortterm strategies that sustain a state or a specific bundle of vested interests not necessarily promote longer-term societal resilience, they can also increase longer-term structural pressures leading to systemic crisis. to a degree this applies also in the case of the black death in england, where the unforeseen longer-term result of the short-term responses was an increase in peasant social mobility and rural social diversity, facilitating a transformation of the labor market and social class relations. this forced the social elite to realign itself with new fiscal and market circumstances in order to protect its socio-economic dominance and at the same time inaugurated a longer-term challenge to its monopoly on local and central political office. nevertheless, there are examples where states possess sufficient systemic resilience to overcome very serious short-term challenges without further exacerbating existing inequalities, as the example of the justinianic plague suggests. while no modern public health infrastructure existed, the imperial government readjusted quickly to meet two immediate needs: burial of the dead and the provision of food supplies for the population. by fulfilling these two duties and when combined with individual self-isolation, constantinople sustained itself and rebounded within just a few years. flexibility built into the imperial administration provided the empire with the capacity to manage a number of (expected) short-term problems, from lower crop yields to catastrophic weather, that allowed the state to mitigate sudden changes to market supply. these short-term strategies secured the stability to meet the state's longer-term strategic aims such as the re-conquest of italy, as well as continuity of administration and government. secondly, our case studies illustrate that states, even where ideologically predisposed to assist the poorest or weakest in society (e.g., the christian eastern roman empire and the islamic ottoman empire) often resolved challenges, both short-term and longer-term, by pushing increased costs for state survival onto those sectors of the society least able to resist-an inevitable consequence of pre-existing systemic inequalities. in the process, however, the state in the past also unconsciously transformed the relationships between the central power and central and regional elites. the great famine in the eastern roman empire that followed the severe winter of 927/928 ce tells exactly this story. this case, along with the example of the catastrophic droughts suffered by the ottomans in the 1590s ce, illustrates how a central government damaged its own economic base when the largest social group, the lower strata of the society, lost its resilience to environmental stress. their vulnerability undermined the foundations of the state's fiscal economy: lack of resilience on the part of the less privileged directly impacted the resources available to the state through taxes and requisitions, thus weakening the core functions of the central government, including the military. a third conclusion is, therefore, that the greater the degree of baseline inequality at the outset of a crisis, the less resilience there is in the system as a whole, the more uneven the distribution of the resilience burden, and the greater the potential for post-solution breakdown of a given social order. social elites, as identifiable groups, generally survive societal crises and transformations because they have a vested interest in preserving their position and generally retain the resources to do so. while individual members or sectors of elites may die or lose their positions of wealth and power, as a visible societal group, they are often still around and at the top of the heap when the dust settles. naturally, there are exceptions: rapid revolutionary events such as in france between 1789 and 1794 or russia in 1917 -1918 can result in the effective removal of much of an established super-elite even if individual members of the old establishment changed sides and joined the revolution. but it is not uncommon, even where a major shift in political and ideological control takes place, for substantial elements of an established elite to adapt to radically changed circumstances and retain their basic socio-economic advantage, even where they are no longer the ruling element. this occurred, for example, with the middling elite of sasanian iran after the islamic conquest in the 640s-650s (pourshariati 2008; morony 1984) ; it was true of the middling elites of the western roman empire (halsall 2007) ; it was true of local balkan elites after the ottoman conquests in the fourteenth-fifteenth centuries ce (kunt 1983; inalcä±k 1973) ; it was just as true of traditional elites throughout the middle east, iran and as far as afghanistan after alexander's conquests in the fourth century bce (adams 2006; erskine 2008) . did people in the past think about system recovery? on a global scale, no. but sectorally, as in the case of central governments with the means at their disposal, the answer varied: the degree of the problems they faced, the nature of economic and social class relationships, and, to some extent, the overall ideology and its key motifs were central factors. did people understand the challenges and respond appropriately? here we have to say, it depends: representatives of religions tended to have a more global outlook (i.e., for people of the same faith), but their responses tended to be moral rather than practical (i.e., prayers to stop the calamity), and when they were practical they were inevitably local and shortterm (i.e., famine relief, for example). ruling elites could respond, but they tended to react primarily to perceived threats to their own survival. this might well embrace the entire state, but as we have seen in some of the examples above, such responses were generally compromised by elite interests, as in the tenth century medieval eastern roman empire. furthermore, they usually were able to respond only to the immediately perceived problem-which may have been just a symptom of deeper issues. and were they able to implement policies to mitigate future risk? yes, but again, for example in the case of antioch, often with unforeseen consequences for the longer term. these historical examples illustrate clearly that policy makers and political leaders today generally have a much greater appreciation of threats and risks, potential and actual-which puts them in a far better position to plan for system recovery. their ability to respond appropriately, however, continues to be determined by a range of cultural/ideological, political/structural, and economic factors, including elite interests, many of which work to constrain or even discourage the implementation of potentially effective policies that could address both short-term challenges and mitigate future risks. this becomes particularly acute when these elite interests do not align with those of the far more numerous non-elites, who are significantly more likely to be affected, as we have seen. in this context, we would suggest that the tendency towards structural socio-economic imbalance in responses to environmental challenges must be a question that future policy planners place at the heart of their calculations. because this sort of imbalance has generally been the case until now does not mean it has to be the case in the future-but in what circumstances this would not occur is an important, largely unanswered, and generally avoided question, except as a statement of general rhetoric. ensuring a more equal and just distribution of the costs and thus extending resilience more evenly across all social-economic sectors would appear to be the obvious solution towards a more sustainable future for any complex socio-political system. the hellenistic kingdoms guns for the sultan: technology, industry, and military power in the ottoman empire robustness, institutions, and large-scale change in social-ecological systems: the hohokam of the phoenix basin panarchy and community resilience: sustainability science and policy implications the black death in egypt and england: a comparative study towns, tax and transformation: state, cities and their hinterlands in the east roman world britain and ireland 1050-1530: economy and society the identity of the plague of justinian the agrarian 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catastrophe: the case of the justinianic plague the justinianic plague: an inconsequential pandemic iraq after the muslim conquest the powerful and the poor in tenth-century byzantium: law and reality aizanoi and anatolia. town and countryside in late late antiquity', millenium a 2800-year multi-proxy sedimentary record of climate change from lake ã�ubuk (gã¶ynã¼k population changes in ottoman anatolia during the 16th and 17th centuries: the 'demographic crisis' reconsidered mgh srl 12. paul the deacon, hanover postan mm (1973) essays on medieval agriculture and general problems of the medieval economy decline and fall of the sasanian empire. the sasanian-parthian confederacy and the islamic conquest of iran. i.b. tauris, new york procopius (1914a) buildings. in: dewing hb (ed) loeb classical library. the macmillan co civilizing climate: social responses to climate change in the ancient near east the justinianic plague: origins and effects oxford stathakopoulos dc (2004) famine and pestilence in the late roman and early byzantine empire: a systematic survey of subsistence crises and epidemics les novelles des empereurs macã©doniens concernant la terre et les stratiotes. centre de recherches byzantines, athens theophanes the confessor, chronographia, c. de boor trade, craft and agricultural production in town and countryside in southeastern isauria the climate of rebellion in the early modern ottoman empire a model disaster: from the great ottoman panzootic to the cattle plagues of early modern europe. in: varlä±k n (ed) plague and contagion in the islamic mediterranean modeling the justinianic plague: comparing hypothesized transmission routes peasant politics and class consciousness: the norfolk rebellions of 1381 and 1549 compared centre de recherche d'histoire et civilisation de byzance. monographies 16 key: cord-301000-ozm5f5dy authors: naqvi, zainab batul; russell, yvette title: a wench’s guide to surviving a ‘global’ pandemic crisis: feminist publishing in a time of covid-19 date: 2020-09-04 journal: fem leg stud doi: 10.1007/s10691-020-09435-1 sha: doc_id: 301000 cord_uid: ozm5f5dy it has been quite a year so far(!) and as the wenches we are, we have been taking our time to collect our thoughts and reflections before sharing them at the start of this issue of the journal. in this editorial we think through the covid-19 pandemic and its devastating effects on the world, on our lives and on our editorial processes. we renew our commitment to improving our operations as a journal and its health along with our own as we deploy wench tactics to restore, sustain and slow down to negotiate this new reality, this new world. we conclude with an introduction to the fascinating contents of this issue along with a collaborative statement of values on open access as part of a collective of intersectional feminist and social justice editors. through all of the pain and suffering we focus our gaze on hope: hope that we can come through this global crisis together engaging in critical conversations about how we can be better and do better as editors, academics and individuals for ourselves, our colleagues and our journal. in these strange times…in these uncertain times…in these unprecedented times. how quickly our conversations and communications have become prefixed with a constant reminder of our current situation. our concern, our sympathies and our connectedness have all increased for one another as we 'check in' with those we interact with regularly, and crucially, those we don't. as pandemic-related lockdowns in the uk and many parts of the world continue, causing many to experience restrictions in their movement and routines that they have never encountered before along with the enforced closure of businesses and places of work, we have been reflecting on the spaces and positions we inhabit as feminist individuals, academics and editors. in this editorial we think through some of the consequences of the covid-19 pandemic and state responses to the spread of the virus in the context of our ongoing efforts to employ decolonising techniques and deploy wench tactics (fletcher et al. 2017; naqvi et al. 2019) . in doing so, we seek to make sense of our new lived realities, although in many ways, just this attempt to make sense of the effects on our existence is both bewildering and revealing. one way this lack of sense is most starkly manifest is in the way it plays with and disrupts time. we experience time as both exponentially sped up and painfully slowed down. over the three months during which we have tried to draft this editorial there have been political, social and economic changes and events too numerous to detail; literally thousands of people have died. but somehow this flux is accompanied by a nagging sense of stasis; we're mulling the same issues, many of us are 'stuck' in our homes with or away from family, and we are still beholden to the virus. this discombobulating confrontation with the contingency of linear time leads us here to feminist work that contemplates time and timeliness and to a necessary reflection on the nature of scholarly work and publishing and the temporal imperatives driving them. in mulling our work and the time in and according to which it occurs, we are also led inevitably to a rumination on health: what is 'health', and who possesses it? the oversimplified answer is that human health refers to our state of physical, mental and emotional wellbeing; and that surely everyone has health which makes it a global concern. unfortunately, we have seen that it really isn't that simple or tidy. fassin (2012) warns us that concern for global health is not something we can take for granted. both 'global' and 'health' are contested concepts (bonhomme 2018) . global health is neither universal nor worldwide; it is not free from the politics of life and the value-giving processes that lead to lives being weighed against each other. the term 'global' is not only a geographical signifier but a "political work in progress that calls on us to remain ever mindful of the imperial durabilities of our time" (biehl 2016 , 128 referring to stoler 2016 . in what follows we reflect further on the lessons of the pandemic and how we view health: as a global public good that we should all be working together to improve and maintain for everyone? or as a privilege that in this patriarchal capitalist society is only available to those who can afford it? we return to the question of time and the timely and try to think collectively with our feminist colleagues about publishing, 'slow scholarship' and wench tactics. we consider what feminist leadership looks like in a time of covid-19 and renew our calls for a firm commitment to decolonising academic publishing and the university. for us, this has recently manifested in a collective statement on publishing and open access, which we have jointly produced and signed with several other intersectional feminist and social justice journal editorial boards. the editorial concludes with an acknowledgement of recently retired editorial board members and an introduction to the copy included in this issue of fls. they are dirty, they are unsuited for life, they are unable, they are incapable, they are disposable, they are non-believers, they are unworthy, they are made to benefit us, they hate our freedom, they are undocumented, they are queer, they are black, they are indigenous, they are less than, they are against us, until finally, they are no more. (indigenous action 2020) a pandemic is the worldwide spread of a new disease (who 2010) in her discussion of affliction, disease and poverty, das (2014) discusses the way in which definitions of global health centre on the control of communicable diseases. controlling the spread of infectious disease between us then, is how we measure the success of global health. along the same vein, the world health organization (who) has defined a pandemic as "the worldwide spread of a disease" (2010). these two statements may seem innocuous but contain layers of historical and contemporary oppressions trapped within their layers of meaning. it would be naive to claim that the covid-19 crisis is the first phenomenon to lay bare the structural injustices and inequalities which already plague us. and that is the key takeaway for us: we are already plagued and have always been plagued with communicable diseases including war, poverty, racism, colonialism, sexism (bonhomme 2018; siyada 2020) . all around the world, lives are lost unnecessarily because of these diseases and now the privileged among us are personally at risk we urgently realise that the status quo is a problem-that we are all fragile (msimang 2020) . these existing diseases have spread worldwide and mutate into new forms all the time: we have been living through multiple, simultaneous pandemics our entire lives and for many of us, this is only now being thrown into stark relief. if we broaden this out further, the editors in us start to inquire into health as a broader concept. health is not only relevant to the human condition but can be applied to systems, processes and institutions such as the academy and the academic publishing industry. the crisis has highlighted the urgent need for us to reflect on the health of our academic lives and spaces along with the ways in which social plagues have infected our ways of writing, editing, working and being. in doing so, we plan and strategise the best ways to be 'wenches in the works' (franklin 2015) taking advantage of this period to deploy wench tactics and rest, restore and sustain. we aim then, to take an all-encompassing approach to health to interrogate the sicknesses and weaknesses that afflict our spaces and worlds and then try to act for change. whilst the who states that a pandemic involves a new disease spreading throughout the world, the current situation shows us that it is not just the spread of this viral pathogen that is causing the pandemic. it is the combination of intersecting oppressions with the spread of the covid-19 viral molecules that make up the pandemic. we always benefit from employing decolonising techniques, by looking back to the past to better understand the present. the history of global health is a neo-colonial project (biehl 2016; magenya 2020 ) mired in imperialist and eurocentric attitudes towards disease control. disease control has been repeatedly used "to bolster the moral case for colonialism" (flint and hewitt 2015, 297) with colonialist administrators considering their ability to control the spread of infectious diseases in the colonies as an important skill. this speaks to their civilising missionary attitude that in purportedly tackling the spread of infectious disease, they were benefitting the natives and their presence was therefore positive (flint and hewitt 2015, 297) . this is further reflected in the international regulations for containing infectious disease spread, which have historically emphasised controls to protect european and north american interests. the us' endorsement of the who prior to its inception in 1969 was predicated on concerns for trading relationships, which were central to us economic growth (white 2020) . the us was only dedicated to "wiping out disease everywhere" when there was a risk disease would enter its borders and affect its economy (white 2020 (white , 1251 . these imperialist attitudes around prioritising the health and economies of majority white countries in europe, north america and australia display the lack of regard for the deaths of those outside of these territories. the spread of cholera in haiti in 2010, the ebola outbreaks (one of which is still ongoing in drc), avian flu, swine flu, and bse have all been deemed epidemics which are not seen as serious or widespread enough to count as pandemics despite the alarming number of sufferers and fatalities. these disease outbreaks all have one thing in common: they affected racialised people in "exotic, far-away and (made-to-be) poor lands" . these are lands that have deficient healthcare systems and resources because of imperial exploitation. this perception of communicable disease outbreaks as afflicting unhealthy and dirty others in far-away places underpins global health approaches and policy along with responses to the outbreaks in the west. even the labelling of the covid-19 crisis as a 'global pandemic' is loaded with meaning: it represents that the disease has spread to and is also killing white people in the west on a mass scale. if it were not affecting this subset of the population in a meaningful way, it would 'just' be an epidemic. this is clearly demonstrated by the uk government's woeful response to the disease and the increasing mortality rate we are experiencing. aaltola states that "diseases exist, flourish and die wider than physical environments where they adapt to local memories, practices and cultures" (2012, 2). by thinking that the uk is invincible because of imperial arrogance, the government has wilfully ignored the memories, practices and cultures of other countries with experience of managing such crises. instead of rushing to save lives, there was a rush to save the economy telling us that there has been no progress in mindset since the 1940s. who suffers the most as a result of this? the marginalised, the poor and the underpaid key workers who are disproportionately not white because diseases are "embedded in and violently react with the fabric of political power" making them "signifiers of the underlying patterns of power" (aaltola 2012, 2; asia pacific forum on women, law and development 2020). the virus may not discriminate but systems and structures by which the imperial state dictates who lives and survives do (anumo 2020; rutazibwa 2020) . this discrimination has spilled onto our streets and into our living rooms with the racist and xenophobic discourses that have led to the unjust treatment of vulnerable minorities in society. from the us president deliberately calling covid-19 the 'chinese virus' to the abuse shouted at east asian people on the streets, reactions to the virus have been rooted in intolerance and ignorance. these unsurprising (and imperialist) responses are further manifested in policy responses which disadvantage the most vulnerable of us including minorities with greater representation in lower socioeconomic groups; victims of abuse who are now told to stay locked up in the house with their abuser; elderly people in care homes or congregate living arrangements; those with 'pre-existing' conditions or disabilities and; immigrants who are being subjected to yet more nationalist rhetoric around border control and surveillance (see also step up migrant women uk 2020 amidst these waves of pain and suffering we reel as we witness the continual devaluing of life with the deaths of breonna taylor on 13 march; belly mujinga on 5 april; george floyd on 25 may; bibaa henry and nicole smallman on 6 june; dominique rem'mie fells on 8 june and riah milton on 9 june. these are just a few of the black women and men whose lives have been cruelly and callously taken this year. the list is endless: bleeding and weeping like an open wound. the black lives matter movement was given the attention it deserves by the national and international media as people took to the streets in solidarity, but the wheels of justice move slowly, grinding regularly to a halt leaving us feeling helpless and hopeless at times. we wanted to express our support and decided to share links to free downloads of our articles on a twitter thread written by black authors and papers that adopt critical race approaches. 1 we have now provided a period of openaccess to some key contributions made by black scholars and activists to fls over the last 27 years. 2 what might have always been an inadequate response/intervention quickly revealed some undeniable shortcomings in the journal, its processes and the academic publishing context we negotiate every day. the lack of contributions published in the journal by black scholars is undeniable and something we intend to reflect further on as a board. we know that this needs to be better and we need to have more critical conversations around realising this. we are not looking for an immediate fix or cure. much like the coronavirus, there is none forthcoming yet. but health for humans and for journals is in a state of constant flux, it is an ongoing journey and we can only keep trying to take steps in the right direction to be the best we can: to affirm the value of black scholarship and black lives and counter the appalling racism of the institutions and operations that has heightened in visibility throughout this pandemic. so, yes, we are afflicted and have been since before this pandemic spread, but amongst the fear and the trauma, this situation has revealed hope in humanity and offered an opportunity to step back and re-evaluate. if what they say is true, things will never be the same again and that's exactly what we need: for things to change for the better; to remind us that our health is our wealth and that we need a (genuinely) global effort towards achieving this and not just for certain parts of the world. as feminist academics, writers, dreamers and above all wenches, we have been thinking about how to best deploy our tactics, our resources and our energies to change the 'global' health of academic publishing for the better. an approach to health which is not geared towards saving the economy of the industry first, but the people, their ideas and creativity, their knowledges from all over this suffering world. this leads to us to try and make sense of the gendered and racialised impacts of the virus and this 'new reality' on the workforce and our work as part of an industry: the academic industry. as is to be expected, the recent crisis has laid bare and exacerbated existing socioeconomic inequalities. in the united kingdom, for example, british black africans and british pakistanis are over two and a half times more likely to die in hospital of covid-19 than the white population (platt and warwick 2020) . researchers speculate that among the reasons for the higher death rates among black, asian and minority ethnic (bame) 3 populations in the uk include the fact that that a third of all working-age black africans are employed in key worker roles, 50% more than the share of the white british population. pakistani, indian and black african men are respectively 90%, 150% and 310% more likely to work in healthcare, where they are particularly at risk, than white british men (siddique 2020) . underlying health conditions which render people more vulnerable to risk from infection are also overrepresented in older british bangladeshi men and in older people of a pakistani or black caribbean background. over 60% of those national health service workers who have died due to covid-19 thus far were from bame ethnic backgrounds (cook et al. 2020) . in addition to these stark ethnic and racial mortality disparities, research continues to emerge attesting to the disproportionate health, social protection and security, care, and economic burdens shouldered by women as the pandemic progresses (united nations 2020). while men appear to carry a higher risk of mortality from the virus, the differential impacts on men and women of covid-19 remain largely ignored by governments and global health institutions, perpetuating gender and health inequities (wenham et al. 2020) . in terms of labour politics, a noticeable shift in working patterns during the pandemic has, perhaps unsurprisingly, disproportionately impacted women. as joanne conaghan observes, the effects of the pandemic are compounded for women due variously to "…their weak labour market position in low paid, highly precarious, and socially unprotected sectors of employment, their greater propensity to be living in poverty, along with the practical constraints which a significant increase in unpaid care work is likely to place on women's ability to pursue paid work" (2020). conaghan points out that the gender division of labour manifests itself in different ways throughout history, affecting the social and economic status of women. but what the covid-19 crisis reveals in this historical time period is the extent to which labouring practices for many have been 'feminised', "not just in the sense that the proportion of women participating in paid work has exponentially increased but also because the working conditions traditionally associated with women's work-lowpaid, precarious, and service-based rather than manufacturing-have become the norm" (conaghan 2020). thus women workers, but also vulnerable young people, migrants, and low-paid precarious workers are further exposed by the "perfect storm of poverty, destitution, sickness and death" generated by covid-19 (conaghan 2020) . how then are these labour realities relevant to us in the academic publishing sector? some editors are reporting a noticeable downturn in submissions by women authors and, in some cases, an upturn in submissions by men (fazackerley 2020) , which would be consistent with conaghan's thesis. the current paradigm, however, provides us with another opportunity to look at the mode of production operating in journal publishing, one that we at fls are implicated in and have long been critical of (fletcher et al. 2016 (fletcher et al. , 2017 . our insistence that academic publishing, and feminist publishing in particular, be seen as a political endeavour drives a lot of our editorial policies including an emphasis on the importance of global south scholarship, employing decolonising techniques in our editorial practice, our involvement in the recent global south writing workshops (naqvi et al. 2019 ) and our continuing support for early career researchers (ecrs), particularly those from marginalised or minoritised communities. 4 we remain troubled, however, by the insidious ambivalence of the neoliberal university as it lumbers on, undeterred and uninterested in the new lives we are all trying to adjust to. it was of serious concern to us, for example, that the ref publication deadline remained unaltered well into the onset of the pandemic with associated impacts on journal editors and boards, reviewers and authors. 5 in another appalling example of how structural disadvantages for black researchers are embedded in the 4 zainab naqvi and kay lalor have recently secured a grant from feminist review trust to run a workshop for 'global south' feminist ecrs based in the uk who work in the social sciences and humanities. see https ://www.femin ist-revie w-trust .com/award s/. 5 we joined with many colleagues in signing this open letter to demand an immediate cancelation of the publication deadline: https ://femre v.wordp ress.com/2020/04/30/call-for-the-immed iate-cance llati on-ofthe-ref-2021-publi catio n-perio d/. 1 may 2020. academy, we are currently watching the unfolding saga of none of the £4.3 million worth of funding allocated by ukri and nihr to investigate the disproportionate impacts of covid-19 on 'bame' communities being awarded to black academics. this is compounded by the revelation that of the 6 grants awarded, 3 had a member of the awards assessment panel as a named co-investigator. 6 many of those in our feminist community have come together over the last four months in various fora to share ideas and to support one another as we both adjust to this new paradigm, and resist the continued imposition of the old one (see, for example, graham et al. 2020) . we took part in collective discussion in july with colleagues on the editorial boards of feminist theory, feminist review, european journal of cultural studies, european journal of women's studies and sociological review about the academic publishing in the context of covid-19. that discussion enabled us to share resources and build morale with a view to envisioning a future for feminist and critical academic publishing. a future in which we challenge existing models of open access in publishing as a starting point. the issues with open access are manifold and we have reflected on these previously (fletcher et al. 2017) . we aim to build and strengthen the links between the board and our fellow social justice and feminist journals to address this along with the other problems that we have identified, experienced and maybe even fed into as editors. as a first step, we have written a collaborative statement on our joint reflections concerning open access which sets out a non-exhaustive list of some of the values we wish to embody as journals and imbue our editorial work and processes with going forward. you can read the collective statement below at the end of this editorial, and we encourage other journals to join and sign the statement. reflecting on what has changed in this time of covid-19 and what has stayed the same has led us back in many ways to where we started with wench tactics (fletcher et al. 2017) . how do we engender our own time and space when what little time and space there is isn't really for us? returning to a conscious consideration of timeliness and to the promise of the decolonial public university might be a way to carve out time and space anew or to resist the pull back to 'normality'. one way of undoing time in the institutional contexts in which we find ourselves is through attempting to articulate and practice an ethics of slowness. mountz and colleagues deploy a feminist ethics of care in trying to reimagine working conditions that challenge the imperatives of the neoliberal university (2015). the authors emphasise the need to prioritise "slow-moving conversation[s] on ways to slow 6 we support this open letter that has been produced by ten black women colleagues to call on ukri for transparency and accountability regarding this: https ://knowl edgei spowe r.live/about /. 18 august 2020. the letter points out that according to hesa data, only 1.3% of full-time research positions in the uk are awarded to black and mixed heritage women exposing the seriousness of this marginalisation where black researchers cannot even get grants to do research with their own communities. down and claim time for slow scholarship and collective action informed by feminist politics" (mountz et al. 2015 (mountz et al. , 1236 . this understanding of slow scholarship is predicated, of course, on a thoroughgoing critique of neoliberal governance and its drivers, which have fundamentally transformed the university in the uk (and elsewhere) over the last 10 years. karin van marle points out how neoliberal epistemologies crowd out other ways of knowing and being such that they become common sense. this has a chilling effect on the university, which "instead of being a space where multiple views and knowledges are celebrated… becomes a very specific place of exclusion and limitation" (2019). van marle insists that we try and think of the university by reference to a different set of aesthetics: "at least it should be one that acknowledges bodily-presence, sensory experiences, complexity and the need to slow down, to step aside from counting, competitiveness and suffocation" (2019). amid covid-19 we are on the precipice of an economic catastrophe for higher education in which many of our colleagues will lose their jobs and the futures of early career researchers and those without permanent jobs is looking more precarious than ever. we are also concerned about those vulnerable and disabled colleagues, pregnant people and others who can't acclimatise to the changes that are going to be demanded of us. we need to combine our ethos of slow scholarship with sustainable collective labour politics that prioritises the most vulnerable among us, and one that is particularly attentive to the disadvantages that devolve in line with the socio-economic/class, race and gender disparities discussed above. that the sector has long been poised on a knife-edge is something that many of our colleagues and unions have been warning about, and in the uk this has become more and more acute as austerity politics ravage the state sector, of which the university used to be a part. the notion of the public university feels often like a concept that is fast fading in our collective consciousness, but publishing, teaching and living in a time of covid-19 makes it prescient once again. as corey robin puts it: "public spending, for public universities, is a bequest of permanence from one generation to the next. it is a promise to the future that it will enjoy the learning of the present and the literature of the past. it is what we need, more than ever, today" (2020). that imagining how we want our world(s) and universities to be is also a profoundly decolonial imperative is something that we must reckon with and take responsibility for (see also, otto and grear 2018). as many institutions of higher learning in the global north have been forced to confront their complicity in the global slave trade and in other forms of imperialism in the wake of #blacklivesmatter, we have to insist on meaningful accountability and not, as foluke adebisi warns, pr stunts or marketing sops to 'diversity' politics (2019). adebisi makes clear the importance of locating ourselves as researchers and teachers as a continuing part of the university's legacy, and the need to acknowledge racism and colonialism as ongoing processes: "my constant fear is that in the process of universities 'coming to terms', our proposals can turn out to be non-contextualised recommendations that do not take into account the embedded and extended nature of slavery and the slave trade" (2019). what if we showed to our students, asks adebisi, "in very concrete terms, exactly how the past bleeds into the present, how we walk side by side with histories ghosts, how we breathe coloniality every day, how our collective history is literally present in every single thing we do?" (2019). in other words, how can we effectively distinguish, asks olivia rutazibwa, between teaching and learning that foregrounds the will to power versus the will to live? by this she means that in our attempts at decolonising we "go beyond the merely representational" by engaging with and understanding the very materiality of being and the systems that determine and produce our lives (and deaths) (rutazibwa 2018, 172) . that such pedagogical and activist praxis necessarily requires time, space and slow conversations is immediately clear. trying to think through slowness in the context of feminist decolonial editorial praxis is also a key aspect of wench tactics (fletcher et al. 2017; fletcher 2020) . being a wench in the works entails us deploying tactics to influence how our journal is used, accessed and circulated. we add to this by now utilising wench tactics to influence how our journal is produced. intrinsic in this is the timeline around production, use, access and circulation. as we work from home, experiencing lockdowns and shielding and distancing, time simultaneously runs away from us and stretches out before us. to ground ourselves then, we take a step back: we step out of the rat race that life has become and prioritise health; for ourselves, for others and for the journal. we first set out to rest and restore. we break out of the increasingly frantic rhythms and deadlines that are being fired at us by our institutions and do something else-we aim to remind ourselves of who we are and what we do. in practical terms, this has reminded us that the production and success of our journal are not dependent on us alone but on others including our amazing authors, reviewers, copyediting team and of course our readers. in recognition of the hard work, commitment and engagement of all these people, we have given extended periods for the different steps in the issue production process from reviews to revisions and even writing this editorial. as we do this, we remain defiant and difficult in the face of the publishing industry's environment which requires constant, enthusiastic engagement. this is mirrored in higher education more broadly as we are inundated with email after email about all the changes we must effect to our teaching, research and general working practices in the upcoming year. we need to rest and take restoration measures; we need time and resources to return to ourselves and using wench tactics is an important way to achieve this. to support our rest and restoration, we have also been guided by slow scholarship principles which sideline the measures of productivity, competition and finances underpinning the current institutional and structural approaches to this crisis. instead we emphasise slower conversations and work to sustain ourselves, our health and the journal. we withdraw from institutional priorities which value automation-levels of speed so that we can sustain critical engagement with ourselves, our editorial practices and one another. we place worth and value then on ways of being and working which sustain us, nourish us and keep us grounded, reminding ourselves and one another that it is completely understandable things will take time, need more time, deserve more time than the industry wants us to believe. again, this requires us to be difficult and defiant; a decolonial feminist technique which reconfigures what is seen as valuable and worthy. here, we critically question what is currently being positioned as valuable and worthy in industrial terms and then re-order the list to move our rest, restoration and sustenance to the top. getting things done is valuable and worthy but ensuring that we are rested and restored so that we can sustain ourselves, our engagement with the work we do, and our health are more so. fls is a community and we have been taking time in our meetings to make the space to check in with one another, hear how each member is doing and to practise building care and solidarity with and for one another. this is not limited to our meetings but even the spaces and platforms outside of our 'formal', scheduled interactions. we aim to be there for each other on social media and in collective and individual ways. in doing so, we seek to model best practices of feminist leadership. inspired by leila billing's writings (2020), we first make the invisible, visible and cultivate cultures of mutual care. we make ourselves visible to one another, and to others-we want to be accessible to all of you and remind our colleagues and readers that like you, we are human beings struggling with our lives, health and commitments during this crisis. we are there for each other in an ongoing state of mutual care. in response to the terrible impacts this crisis and the already toxic aspects of the academy are having on minoritised ecrs and to make us more visible and model these mutual care principles, zainab and kay have secured funding to run a writing and mentoring workshop for 'global south' feminist ecrs in the social sciences and humanities based in the uk. more information will be released on our social media channels, so please look out for it and apply if you are eligible and interested. finally, we want to model feminist leadership by imagining and celebrating alternatives. this is exhibited in our recent work to imagine what a life after existing models of open access could and should look like with our colleagues from other feminist and social justice journals (see below). the dreamers inside us envisage alternative ways to share our research and celebrate forms and productions of knowledges that are not given enough attention by us or the academy. in her work around complaint sara ahmed advances the formation of the 'complaint collective' (2019). when we complain, we object to something that should not be happening, but also because we are hopeful about how things could be different (ahmed 2017) . as we speak out against existing publishing models, we are optimistic about how things can change and become connected with others who have the same complaints and same hope. this leads us to form a complaint collective with our fellow editors and those who are also concerned about the status quo giving us the necessary space, time and opportunity to collaboratively imagine, celebrate and speak out in hope for an alternative model of publishing that is healthier, more equitable and representative. change and movement are inevitable and as we face the challenges of the present and dream about how we can make things better for the future, we now celebrate several of our cherished colleagues who are moving on to new and exciting things. before we introduce the papers that make up this issue of the journal, we want to acknowledge the work of our colleagues who have recently retired from their roles on the editorial board of fls. julie mccandless, nicola barker and diamond ashiagbor are irreplaceable members of our collective and we already miss their sage wisdom, warmth and dedication to fls. all three joined the fls editorial board in 2014, when the journal became independent of the university of kent and were instrumental in guiding the journal as it has grown over the last six years. julie mccandless is a powerhouse whose commitment to and influence on fls cannot be overstated. she was a co-ordinating editor for the journal for most of her tenure and authors will remember her thoroughness, care and generosity as an editor. nicola barker was a book reviews editor during her time on the board and her invaluable contributions to our lively discussions and decision-making processes filled our time together with warmth and laughter. finally, diamond ashiagbor, as well as serving as a book review editor for a significant period of her tenure, brought such vast experience and rigour to her role on the editorial board we will dearly miss her wise counsel. we send our love and solidarity with these wonderful colleagues (and fellow wenches) and wish them well as they continue to blaze a feminist trail for us. and so, we are on the lookout for some more wonderful colleagues to join our editorial board. we have released a call for members aiming to recruit colleagues from the uk and ireland through an application process. if you are interested in joining the board, please do apply. we want the board to be as representative as possible and especially encourage colleagues with a feminist background at any career stage from minoritised groups to apply. if you have any questions about applying, please do get in touch with us, we would be delighted to tell you just how much fun it is to be a wench in the works. this issue of the journal includes some remarkable feminist legal scholarship, notable for its breadth, both scholarly and geographically. caroline dick's article entitled 'sex, sexism, and judicial misconduct: how the canadian judicial council perpetuates sexism in the legal realm' is a fascinating and sobering look bias in decisions of the canadian judicial council. dick considers two separate judicial misconduct complaints adjudicated by the council, one in which a male judge exhibited bias against women while adjudicating a sexual assault trial and a second in which graphic, sexual pictures of a female judge were posted on the internet without her knowledge or consent. dick concludes that the decisions of the council indicate that it is itself perpetuating gendered stereotypes informed by the notional ideal victim, further perpetuating sexism both in canadian courtrooms and among the judiciary. in our second article of this issue, maame efua addadzi-koom carefully examines the history and effectiveness of the 2003 maputo protocol, a uniquely african instrument on women's rights that was established with the promise of addressing the regional peculiarities of african women. analysing what little case law there is invoking the protocol and concerning gender-based violence against women, addadzi-koom takes stock of the potential of the protocol and the burgeoning due diligence principle on the women's rights jurisprudence of the ecowas community court of justice (eccj). addadzi-koom concludes her discussion with some recommendations arguing that the protocol and the due diligence principle should be more widely applied by the eccj to centre women's rights in the sub-region and beyond. in '"is this a time of beautiful chaos?": reflecting on international feminist legal methods' faye bird delves deep into feminist jurisprudence with an intriguing interrogation of margaret radin's work, and in particular, her distinction between 'ideal' and 'non-ideal' to evaluate different methodologies for critiquing international law and institutions. bird asserts that (re)viewing radin's framework in this context presages a new and more fruitful feminist pluralism through which we might better navigate institutional strategising. having featured heavily in faye bird's foregoing article, in our next paper dianne otto reflects artfully on the latest iteration of the feminist judgments project in her review essay: "feminist judging in action: reflecting on the feminist judgments in international law project". otto observes aspects of the feminist judgments that were transformative, before turning to the contributors' 'reflections', which highlight some of the obstructions encountered and compromises made in the processes of judging. otto concludes that the new collection makes a useful and compelling contribution to concretising feminist methods and highlighting the role of international jurisprudence as a feminist endeavour, while contributing to the insight of the feminist judgments project more broadly by exposing the scope and limits of justice delivered by the legal form of judging. the issue is completed by book reviews of three exciting new titles, all of which speak to issues of immediate concern to feminist legal scholars: eva nanopoulos reviews honor brabazon's wonderful edited collection neoliberal legality: understanding the role of law in the neoliberal project; lynsey mitchell considers the research handbook on feminist engagement with international law, edited by susan harris rimmer and kate ogg and; felicity adams reviews emma k russell on queer histories and the politics of policing. we are, as always, eternally grateful for the generosity and collegiality of our reviewers, without whom the journal could not function. we conclude this editorial with the recently written feminist and social justice editors' collaborative statement of intent on the values and principles we wish to adopt and embody in our work and efforts to survive, thrive and maybe even dismantle parts of the academic publishing machine. our journey and vital conversations around and towards health continue as we try to become better editors, academics and women: taking the time and resources, to be our best (and healthiest) wench selves. we are a collective of intersectional feminist and social justice journal editors. we reject the narrow values of efficiency, transparency and compliance that inform current developments and policies in open access and platform publishing. together, we seek further collaboration in the development of alternative publishing processes, practices and infrastructures imbued with the values of social and environmental justice. the dominant model of open access is dominated by commercial values. commercial licenses, such as cc-by 7 are mandated or preferred by governments, funders and policy makers who are effectively seeking more public subsidy for the private sector's use of university research, with no reciprocal financial arrangement (berry 2017) . open access platforms such as academia.edu are extractive and exploitative. they defer the costs of publishing to publishers, universities and independent scholars, while selling the data derived from the uses of publicly funded research. as such they represent the next stage in the capitalisation of knowledge. commercial platforms are emphatically not open source and tend towards monopoly ownership. presenting themselves as mere intermediaries between users, they obtain privileged access to surveil and record user activity and benefit from network effects. a major irony of open access policy is that it aims to break up the giants of commercial journal publishing but facilitates existing or emerging platform monopolies. the tech industry-now dominating publishing, and seeking to dominate the academy through publishing-having offered open access as a solution to the ills of scholarly publishing is currently offering solutions to the problems caused by open access including discoverability, distribution, digital preservation and the development and networking of institutional repositories that stand little to no chance of competing with academia.edu. platforms are not only extractive but have material effects on research, helping to effect a movement upstream in the research cycle whereby knowledge is redesigned, automatically pre-fitted for an economy based on efficiency, competition, performance, engagement or impact. alongside the transformative agreements currently being made between commercial journal publishers (mainly) and consortia led by powerful universities, publishers such as elsevier are gaining greater access to the research cycle and to the data currently owned by universities. open access benefits commercial interests. the current model also serves to sideline research and scholarship produced outside of universities altogether, creating financial barriers to publishing for scholars outside of the global north/west and for independent scholars, as well as for early career researchers and others whose institutional affiliation is, like their employment status, highly precarious and contingent, and for authors who do not have the support of well-funded institutions and/or whose research is not funded by research councils. moreover, stem fields and preprint platforms are determining the development of open access publishing cultures. these are forms of content management that offer cost reduction and other efficiencies by erasing the publisher and minimising editorial function. they raise questions of quality assurance and further the technologisation, standardisation and systematisation of scholarly research such as the automation of peer review, and the disaggregation of journals and books into article or article-based units that can be easily monitored and tracked. therefore, the underlying values of widening participation, public knowledge and the fair sharing of resources need to be reclaimed. platforms should be refitted for ahss scholarship (where speed, for example, is not an indicator of the importance of research) and integrated with more conventional modes of dissemination and distribution more suited to the field and its preference for print monographs. platform development should be distributed and institutionally owned and instead of replacing the publisher-as-problem, it should recognise and represent a more diverse set of publishing interests, stemming from scholar-led and university press publishers that are mission-driven and not-for-profit. it should enable and sustain the innovation generated through intellectual kinship across diaspora spaces. open access reaches into, and disrupts the academy through policy mandates that are, at present, unfunded or underfunded and that defer more of the costs of publishing onto a sector that could not support them even before the covid-19 pandemic and its catastrophic effect on institutional finances as well as individual lives and wellbeing. as a collective of feminist and social justice journal editors we believe that journal publishing during and after the pandemic should seek to end the exploitation of scholarly labour and foreground a new ecological economics of scholarly publishing based on cooperation and collaboration instead of competition; responsible householding, or careful management of the environment rather than the extraction; and the fair-sharing of finite resources (such as time and materials). rather than extracting more resource (including free labour) from an already depleted and uneven sector, thereby further entrenching inequalities within and between universities globally, and sidelining scholarship produced outside of universities altogether, journal publishing after open access should be responsive and responsible toward the wellbeing, values and ambitions of diverse scholars and institutions across ahss and stem in the global south and the global north. we will learn from, and engage with other collaborative ventures such as amel-ica in latin america, 8 coko in the us 9 and copim in the uk. 10 building on these initiatives, which are primarily concerned with implementing open science or open humanities agendas, we are inaugurating a more radical project of reevaluating and reorganising journal publishing: • replacing the values of efficiency, transparency and compliance with those of equality, diversity, solidarity, care and inclusion • providing a more sustainable and equitable ecological economics of scholarly publishing in tune with social and environmental justice • working collectively and collaboratively rather than competitively • thinking and acting internationally, rather than through parochial national or regional policies • working across publishing and the academy with a view to responsible householding and accountability in both sectors • seeking to work across funding and institutional barriers, including between stem and ahss scholars • seeking further collaborations and partnerships in order to build new structures (disciplines, ethics, processes and practices of scholarship including peer review, citation, impact, engagement and metrics) and infrastructures to support a more healthy and diverse publishing ecology • challenging the technologisation and systematisation of research by working to increase our visibility as editors and academics making us and our publications more accessible and approachable for those who are minoritised in academic publishing publishing after open access does not have a resolution (let alone a technological solution) or endpoint, but rather is a continual process of discussion, controversymaking and opening up to possibilities. we do not know what journal publishing after open access is, but we do know that we must work together in order to create a just alternative to the existing extractive and predatory model, an alternative that operates according to a different set of values and priorities than those that dominate scholarly publishing at the moment. these values and priorities need to inform or constitute new publishing systems committed to the public ownership rather than the continued privatisation of knowledge. we recognise that the choice we face is not between open and closed access, since these are coterminous, but between publishing practices that either threaten or promote justice. we fully recognise the scale of the challenge in promoting justice against the global trend of entrenched populism, nationalism and neoliberalism. collective action and intervention is a start point, and we take inspiration from the recent statement issued by the black writers' guild. 11 our open exploration of the future of journal publishing will be informed by the history of radical and social justice publishing and by intersectional feminist knowledge and communication practices that are non-binary, non-hierarchical, situated, embodied and affective. against the instrumentalisation and operationalisation of knowledge, we will foreground both validation and experimentation, authority and ethics. we will ask, against a narrow implementation of impact and metrics, what really counts as scholarship, who gets to decide, who gets counted within its remit, and what it can still do in the world. we believe that knowledge operates in, rather than on the world, co-constituting it, rather than serving as a form of mastery and control. the re-evaluation of knowledge and its dissemination is, therefore, we believe, a necessary and urgent form of re-worlding. we are open to other journals joining this collective. if you are interested please get in touch with any of the signatories below: european journal of cultural studies european journal of women's studies feminist legal studies feminist theory the sociological review understanding the politics of pandemic scares: an introduction to global politosomatics complaint as diversity work why complain? feministkilljoys unchecked corporate power paved the way for covid-19 and globally, women are at the frontlines. cambridge core covid-19 highlights the failure of neoliberal capitalism: we need feminist global solidarity the uses of open access. stunlaw, philosophy and critique for a digital age theorizing global health what does feminist leadership look like in a pandemic? medium epidemics and global history: the power of medicine in the middle east coronavirus, colonization, and capitalism. common dreams exclusive: deaths of nhs staff from covid-19 analysed covid-19 and inequalities at work: a gender lens. futures of work affliction: disease health and poverty (forms of living) that obscure object of global health women's research plummets during lockdown -but articles from men increase. the guardian on being uncomfortable wench tactics? openings in conditions of closure playing with the slow university? thinking about rhythm, routine and rest in decelerating life. presentation at qmul 18 sexism as a means of reproduction: some reflections on the politics of academic practice colonial tropes and hiv/aids in africa: sex, disease and race dialogue on the impact of coronavirus on research and publishing indigenous action. 2020. rethinking the apocalypse: an indigenous anti-futurist manifesto making a feminist internet in africa: why the internet needs african feminists and feminisms for slow scholarship: a feminist politics of resistance through collective action in the neoliberal university homesick: notes on a lockdown back at the kitchen table: reflections on decolonising and internationalising with the global south sociolegal writing workshops international law, social change and resistance: a conversation between professor anna grear (cardiff) and professorial fellow dianne otto (melbourne) are some ethnic groups more vulnerable to covid-19 than others? the institute for fiscal studies the pandemic is the time to resurrect the public university. the new yorker on babies and bathwater: decolonizing international development studies the corona pandemic blows the lid off the idea western superiority https ://olivi aruta zibwa .wordp ress.com/2020/04/12/the-coron a-pande mic-blows -the-lid-off-the-idea-ofweste rn-super iorit what they did yesterday afternoon british bame covid-19 death rate 'more than twice that of whites'. the guardian coronavirus pandemic in the shadow of capitalist exploitation and imperialist domination of people and nature-statement by the regional secretariat for the north african network for food sovereignty. committee for the abolition of illegitimate debt migrant women: failed by the state, locked in abuse duress: imperial durabilities in our times. durham: duke up. united nations. 2020. policy brief: the impact of covid-19 on women. 9 april life is not simply fact" -aesthetics, atmosphere & the neoliberal university covid-19: the gendered impacts of the outbreak the art of medicine -historical linkages: epidemic threat, economic risk, and xenophobia 