Black Residents Research Articles

“That’s why we’re speaking up today”: exploring barriers to overdose fatality prevention in Indianapolis’ Black community with semi-structured interviews

BackgroundOpioid overdose deaths are of great concern to public health, with over one million lives lost since 1999. While many efforts have been made to mitigate these, Black communities continue to experience a greater burden of fatalities than their white counterparts. This study aims to explore why by working with Black community members in Indianapolis through semi-structured interviews.MethodsSemi-structured one-on-one in-depth interviews were conducted in spring and summer of 2023 with Black residents (N = 23) of zip codes 46202, 46205, 46208, and 46218 in Indianapolis. Ten interview questions were used to facilitate conversations about opioid overdoses, recovery, fatality prevention tools such as calling 911 and naloxone, law enforcement, and racism. Data were analyzed using grounded theory and thematic analysis.ResultsInterviews revealed access barriers and intervention opportunities. Racism was present in both. Mental access barriers such as stigma, fear, and mistrust contributed to practical barriers such as knowledge of how to administer naloxone. Racism exacerbated mental barriers by adding the risk of race-based mistreatment to consequences related to association with substance use. Participants discussed the double stigma of substance use and being Black, fear of being searched in law enforcement encounters and what would happen if law enforcement found naloxone on them, and mistrust of law enforcement and institutions that provide medical intervention. Participants had favorable views of interventions that incorporated mutual aid and discussed ideas for future interventions that included this framework.Conclusions Racism exacerbates Blacks' mental access barriers (i.e., help-seeking barriers), which, in turn, contribute to practical barriers, such as calling 911 and administering naloxone. Information and resources coming from people within marginalized communities tend to be trusted. Leveraging inter-community relationships may increase engagement in opioid overdose fatality prevention. Interventions and resources directed toward addressing opioid overdose fatalities in Black communities should use mutual aid frameworks to increase the utilization of the tools they provide.

Temporal trends in sociodemographic composition and land development within U.S. fenceline communities surrounding hazardous industrial facilities: 2001–2019

Unintended releases from industrial facilities can expose fenceline communities to hazardous substances, and distance between facilities and nearby residential development can play a role in preventing exposures. Here, we assess trends in fenceline community sociodemographic characteristics, land development, and the association between the two using sociodemographic data for census tracts (n = 34 068) surrounding 2457 petroleum refining and chemical manufacturing facilities between 2001 and 2019. We find a higher median growth in percentage of Latinx populations among fenceline communities compared to neighboring communities with no industrial facilities. The increase in the median percentage of Latinx populations within fenceline communities was six times higher than for White populations overall (+6 and +1 percentage points, respectively). Though the percentage of the Black populations did not change within fenceline communities over this period, we find a minor sustained higher percentage of Black residents within fenceline communities relative to neighboring communities (20% versus 19%, respectively). Employing a spatial autoregressive model with autoregressive disturbances, we find that an increase in community percentage Latinx population is associated with a decrease in the rate of land development. Comparing fenceline and neighboring communities, we conclude that Black and Latinx populations are disproportionately located near industrial facilities, potentially contributing to inequitable exposure to unintended chemical releases. Our work lends support to the value of considering of sociodemographic composition of fenceline communities when evaluating industrial facility hazards.

Examining discrimination in home improvement financing (Home Mortgage Disclosure Act 2012–2016) and neighborhood health in the United States

ABSTRACT Institutional racism by financial institutions historically denied Black homeowners access to home mortgage loans. An understudied aspect of the homeownership continuum is home repair and maintenance, with few studies assessing discrimination in access to funding for home improvement. Using US Home Mortgage Disclosure Act data between 2012 and 2016, we assess individual and census-tract level predictors of applying to, and being denied home improvement loans. We find non-Hispanic Black applicants are significantly more likely to be denied loans (OR: 2.28 p < 0.01), and that loans for areas with a high proportion of non-Hispanic Black residents (OR: 1.09, p < 0.01) are most likely to be denied, while applications in tracts with the highest proportion of non-Hispanic white residents (OR: 0.90, p < 0.01) are least likely to be denied. We find that white (r = 0.203), but not Black (r = 0.02) home improvement applications are correlated with the proportion of Black residents currently residing in the census tract. Additionally, at the census tract level, home improvement loan denial rates are associated with usually getting less than 7 hours of sleep, which is associated with adverse health outcomes. Future research on institutional racism should consider the social and health impacts of discrimination in home improvement loan financing for Black applicants and within Black communities.

Racial/ethnic differences in receipt of naloxone distributed by opioid overdose prevention programs in New York City

IntroductionWe evaluated racial/ethnic differences in the receipt of naloxone distributed by opioid overdose prevention programs (OOPPs) in New York City (NYC).MethodsWe used naloxone recipient racial/ethnic data collected by OOPPs from April 2018 to March 2019. We aggregated quarterly neighborhood-specific rates of naloxone receipt and other covariates to 42 NYC neighborhoods. We used a multilevel negative binomial regression model to assess the relationship between neighborhood-specific naloxone receipt rates and race/ethnicity. Race/ethnicity was stratified into four mutually exclusive groups: Latino, non-Latino Black, non-Latino White, and non-Latino Other. We also conducted racial/ethnic-specific geospatial analyses to assess whether there was within-group geographic variation in naloxone receipt rates for each racial/ethnic group.ResultsNon-Latino Black residents had the highest median quarterly naloxone receipt rate of 41.8 per 100,000 residents, followed by Latino residents (22.0 per 100,000), non-Latino White (13.6 per 100,000) and non-Latino Other residents (13.3 per 100,000). In our multivariable analysis, compared with non-Latino White residents, non-Latino Black residents had a significantly higher receipt rate, and non-Latino Other residents had a significantly lower receipt rate. In the geospatial analyses, both Latino and non-Latino Black residents had the most within-group geographic variation in naloxone receipt rates compared to non-Latino White and Other residents.ConclusionsThis study found significant racial/ethnic differences in naloxone receipt from NYC OOPPs. We observed substantial variation in naloxone receipt for non-Latino Black and Latino residents across neighborhoods, indicating relatively poorer access in some neighborhoods and opportunities for new approaches to address geographic and structural barriers in these locations.

How International Style Modernism Came to Dominate in Apartheid Architecture in 1960s South Africa

A review of Hilton Judin, Architecture, State Modernism and Cultural Nationalism in the Apartheid Capital, Routledge, The ARCHITEXT Series, Thomas A. Markus and Anthony D. King, eds. London and New York. 2021. Judin’s book captures a significant moment in South Africa’s architectural history: the economic surge of the 1960s and its attendant building boom. He explores how International Style modernism was harnessed in the design of monumental state buildings in Pretoria, the country’s administrative capital and the heartland of Afrikaner nationalism, while simultaneously being used to corral black residents into segregated dormitory townships on the city’s periphery.

MICEAL Black and Latinx Perspectives on COVID-19 Vaccination: A Mixed-Methods Examination.

To describe the differences and similarities in perceptions and attitudes regarding COVID-19 vaccination among Black and Latinx Michiganders. Utilizing a convergent mixed-methods approach, forty interviews were conducted with 24 Black and 16 Latinx community members between December 2020 and June 2021 across four Michigan counties disproportionately affected by COVID-19. Survey data were collected from a representative sample of 1598 individuals living in Detroit between January and March 2021. Vaccine hesitancy was a more prevalent theme among Black interview participants than Latinx participants. Trust in experts and vaccine access were significantly more influential in the decision to vaccinate for Latinx residents compared to Black residents. Latinx individuals reported greater intention to receive a COVID-19 vaccine compared to Black respondents. Multinomial logit models revealed that 30% of Black participants expressed hesitancy about the COVID-19 vaccine compared to 10% of Latinx respondents. This study provides a deeper understanding of key differences and similarities in vaccine acceptance/hesitancy across race/ethnicity. The findings can enhance health interventions and outcomes by informing the development of culturally responsive practices tailored to specific communities.

Impact and Equity of New York City's Tobacco Retail Reduction Initiative

High levels of tobacco retailer density in communities is associated with a range of tobacco use behaviors and is a key structural driver of tobacco-related disparities. This study evaluates the impacts of New York City's (NYC) novel policy intervention to cap tobacco retail licenses on tobacco retailer density levels and neighborhood inequities in tobacco access. Using geocoded tobacco retail licensing data from 2010 to 2022, Bayesian conditional autoregressive Poisson panel models estimated the association between policy implementation in 2018 and retailer density per 1,000 population, controlling for neighborhood-level sociodemographic factors. Data were analyzed in 2023. The number of tobacco retail licenses decreased from 9,304 in 2010 to 5,107 in 2022, with the rate of decline significantly accelerating post-policy (-14·2% versus -34·2%). Policy effects were stronger in districts with lower income and greater proportions of non-Hispanic Black residents. NYC's policy substantially reduced tobacco retailer density and appeared to close longstanding patterns of inequity in tobacco access, serving as a rare example of a tobacco control policy that may effectively reduce tobacco-related disparities. This emergent approach to restructure tobacco retail in communities may reach populations that have not benefitted from traditional tobacco control policies and should be considered by other localities.

Trends in Cardiovascular Disease Mortality by County-Level Social Vulnerability Index in the United States.

Background Although cardiovascular mortality(CVM) rates in the United States have been declining overall, our study evaluated whether this holds true for areas with increased social deprivation. Methods and Results We used county-level cross-sectional age-adjusted CVM rates (aa-CVM) (2000-2019) linked to the Centers for Disease Control and Prevention Social Vulnerability Index (SVI-2010). We grouped counties as per SVI (Groups I 0-0.2, II 0.21-0.4, III 0.41-0.6, IV 0.61-0.8, and V 0.81-1) and calculated the relative change in the aa-CVM between 2000 to 2003 and 2016 to 2019. We used adjusted linear regression analyses to explore the association between a higher SVI and temporal aa-CVM improvement; we studied this temporal change in aa-CVM across subgroups of race, sex, and location. The median aa-CVM rate (per 100 000) was 272.6 (interquartile range [IQR]: 237.5-311.7). The aa-CVM was higher in men (315.6 [IQR: 273.4-363.9]) than women (221.3 [IQR: 189.6-256.7]), and in Black residents (347.2 [IQR: 301.1-391.1]; P<0.001) than White residents (258.9 [IQR: 226-299.1]; P<0.001). The aa-CVM for SVI I (233.6 [IQR: 214.8-257.0]) was significantly lower than that of group V (323.6 [IQR: 277.2-359.2]; P<0.001). The relative reduction in CVM was significantly higher for SVI group I (32.2% [IQR: 24.2-38.4]) than group V (27.2% [IQR: 19-34.1]) counties. After multivariable adjustment, a higher SVI index was associated with lower relative improvement in the age-adjusted CVM (model coefficient -3.11 [95% CI, -5.66 to -1.22]; P<0.001). Conclusions Socially deprived counties in the United States had higher aa-CVM rates, and the improvement in aa-CVM over the past 20 years was lower in these counties.

Living Among Confederate Icons: Perpetuating White Supremacist Beliefs and Blindness to Black Suffering

Almost 160 years after the American Civil War, where the Union defeated the Confederacy and ended slavery in the United States, approximately 1,910 tributes remain to Confederate military leaders located on public property in the 11 original Confederate states, particularly in cities with an exceptionally high density of Black residents. To Blacks, this iconography delivers a clear message of White supremacy. Six states have enacted laws to protect and preserve these memorials, making it almost impossible to use the court system to move them to private property. This paper explores connections between support for a myth called the Lost Cause, which is a revisionist history intended to spread misinformation about the true cause of the American Civil War, and attitudes toward placement of Confederate symbols on public land. We show that there is significant belief in the Lost-Cause myth among many White U.S. Southerners. Furthermore, we find those who believe most in the myth are the least likely to want to move the monuments or end taxpayer support for their maintenance.

Flood Risk Mapping and the Distributional Impacts of Climate Information

This paper examines the provision of official flood risk information in the United States and its distributional impacts on residential flood insurance take-up. Assembling new data on all flood maps produced after Hurricane Katrina, I first document that updated maps decreased the number of properties zoned in high-risk floodplains and incorrectly omitted five million properties that should have been rezoned inside these areas. Removals and omissions disproportionately occurred in neighborhoods with more Black and Hispanic residents. Leveraging the staggered timing of map updates, I estimate they decreased flood insurance take-up and exacerbated racial disparities in insurance coverage. These effects are driven by beliefs about risks and regulatory constraints. Correcting flood maps could increase welfare by $20 billion annually, but past updates decreased welfare due to distorted risk and price signals.

Prostate Cancer in New York City: Impact of Neighborhood Level Social Determinants of Care

Social determinants of health may impact stage and aggressiveness of cancer presentation. As neighborhoods may influence adjacent neighborhoods across often porous and arbitrary borders, an analysis that measures the spatial impact of these social determinants provides a more holistic evaluation than an analysis that treats each neighborhood as independent and unrelated units. In this paper, we study the impact of sociodemographic and environmental characteristics of neighborhoods on cancer presentation in New York City, using both patient-level analysis and spatial autoregression on the New York State Public Access Cancer Epidemiology Data (NYSPACED) and the NYC Open neighborhood-level dataset. Two outcomes of interest were chosen: Presentation with high grade prostate cancer and presentation with distant disease. We performed logistic regression on individual patient level analysis. We created generalized cross sectional autoregressive spatial regression models to assess direct and indirect (via adjacent neighborhoods) impact of neighborhood level independent variables. We analyzed the following neighborhood level variables: 1) Percent population that was Black, 2) Percent population living in poverty, 3) Percent population obese based on self-reported height and weight, 4) Percent who report being current smokers, 5) Percent who report eating one or more servings of fruits and/or vegetables in the last day, and 6) annual average micrograms of fine particulate matter per cubic meter of air. We identified 95,749 patients diagnosed with prostate adenocarcinoma in New York City from 2001-2018. With reported Black race as the referent value, White patients were less likely to present with high grade disease (OR 0.92 [95% CI 0.89-0.95]). Similarly, self-identified White patients were also less likely to present with distant disease (vs. Black, OR 0.76 [95% CI 0.72-0.81]). Spatial autoregression models revealed no neighborhood level variables associated with direct or indirect impacts on presentation with high grade disease. However, there were several variables initially associated with distant disease presentation, including race, poverty, obesity, fruit and vegetable consumption, and air pollution. However, only neighborhood poverty and obesity levels continued to have significant direct impact on presentation with distant disease when included in the regression model with percent Black residents. In conclusion, we discovered a strong association between Race and poverty with the likelihood of presenting with advanced prostate cancer, at both the individual and neighborhood levels. Geographically targeted outreach to improve prostate cancer screening and access to care should be focused on Black men and neighborhoods with high levels of poverty.

Uncertainty Reduction and Environmental Justice in Air Pollution Epidemiology: The Importance of Minority Representation.

Ambient air pollution is an increasing threat to society, with rising numbers of adverse outcomes and exposure inequalities worldwide. Reducing uncertainty in health outcomes models and exposure disparity studies is therefore essential to develop policies effective in protecting the most affected places and populations. This study uses the concept of information entropy to study tradeoffs in mortality uncertainty reduction from increasing input data of air pollution versus health outcomes. We study a case scenario for short-term mortality from particulate matter (PM2.5) in North Carolina for 2001-2016, employing a case-crossover design with inputs from an individual-level mortality data set and high-resolution gridded data sets of PM2.5 and weather covariates. We find a significant association between mortality and PM2.5, and the information tradeoffs indicate that a 10% increase in mortality information reduces model uncertainty three times more than increased resolution of the air pollution model from 12 to 1km. We also find that Non-Hispanic Black (NHB) residents tend to live in relatively more polluted census tracts, and that the mean PM2.5 for NHB cases in the mortality model is significantly higher than that of Non-Hispanic White cases. The distinct distribution of PM2.5 for NHB cases results in a relatively higher information value, and therefore faster uncertainty reduction, for new NHB cases introduced into the mortality model. This newfound influence of exposure disparities in the rate of uncertainty reduction highlights the importance of minority representation in environmental research as a quantitative advantage to produce more confident estimates of the true effects of environmental pollution.

Smartphone Data Reveal Neighborhood-Level Racial Disparities in Police Presence

Abstract Research on policing has focused on documented actions such as stops and arrests—less is known about patrols and presence. We map the neighborhood movement of nearly ten thousand officers across 21 of America's largest cities using anonymized smartphone data. Police spend 0.36% more time in neighborhoods for each percentage point increase in Black residents. This neighborhood-level disparity persists after controlling for density, socioeconomic, and crime-driven demand for policing, and may be lower in cities with more Black police supervisors (but not officers). Patterns of police presence statistically explain 57% of the higher arrest rate in more Black neighborhoods.

Favela Heritage Practices: Women Warriors’ Struggles for Political Memory and Social Justice in Rio de Janeiro

ABSTRACT This article discusses everyday spatial heritage practices in Rio de Janeiro’s favelas. It focusses on the experiences of faveladas, Black and poor women residents of the favelas, as they build their houses and struggle for political memory in the city. Based on ethnographic fieldwork and photowalks conducted in 2011–2013 and 2018 with residents of the favelas of Pavão-Pavãozinho and Cantagalo (PPG), this article documents the insurgent heritage practices of ‘women warriors’ and analyses the ways in which these practices typify means of resistance to urban coloniality. I draw on theories by the Afro-Brazilian feminist scholars and activists Beatriz Nascimento on quilombos (maroon communities) and Lélia Gonzalez on ‘Amefricanity’, who recourse to black and indigenous women’s Southern Atlantic experiences of oppression and forced migration and of resistance, to suggest the notion of ‘Amefrican’ heritage practices. The women warriors’ spatial practices and resistance encompass curated favela heritage. They challenge prejudice against the favelas and Afro-Brazilians, thereby sustaining ‘Amefrican’ heritage practices and shaping Rio de Janeiro’s cultural heritage and future, especially against contemporary processes of urban coloniality.

Diversity in Radiology Residents Relative to Other Specialties— Trends Over the Past Decade

The objective of this study was to assess diversity among radiology residents relative to other specialties and compare it with historical trends. The Graduate Medical Education results from 2010-2011 to 2020-2021 were accessed for demographic information for major medical specialties (number of residents > 500 as of the 2020-2021 report). Subspecialties and fellowship programs were not included in this analysis. The racial and ethnicity breakdowns were extracted, including Black, White/Caucasian, Asian, Hispanic, and others. The changes in racial and ethnicity composition of residents in radiology was compared to other specialties using the Chi Squared test using a significance level of p < 0.05. In 2020-2021, radiology ranked ninth in total resident enrollment among the 21 largest ACGME training programs, unchanged when compared to 2010-2011. Amongst all specialties, Radiology ranked 10th for Black and 9th for Hispanic representation in 2020-2021.The percentage of Black residents increased from 3.07% in 2010-2011 to 3.83% in 2020-2021. The percentage of Hispanic Radiology residents increased from 4.83% to 7.35%, constituting the third largest increase amongst all specialties. The representation of Blacks and Hispanics in Radiology has improved relative to other medical specialties in the last decade.

“OK at the moment”: The important role listening plays in the relationship between black residents and local government

Researchers surveyed 501 Black U.S. residents to examine the impact of listening on trust, satisfaction, commitment, and attitude toward participants' hometowns. Results indicate listening plays an important role in organization-public relationship (OPR) outcomes, and that satisfaction mediates the impact of listening on city attitude and likelihood to recommend a city. Qualitative responses reveal a tenuous relationship between Black residents and local government. Listening should be prioritized in future OPR scholarship and city government communicators’ practice.

Geospatial Distribution of Racial Disparities in Influenza Vaccination in Nursing Homes

ObjectivesThis study aimed to assess the distribution of racial disparities in influenza vaccination between White and Black short-stay and long-stay nursing home residents among states and hospital referral regions (HRRs). DesignRetrospective cohort study. Setting and ParticipantsWe included short-stay and long-stay older adults residing in US nursing homes during influenza seasons between 2011 and 2018. Included residents were aged ≥65 years and enrolled in Traditional Medicare. Analyses were conducted using resident-seasons, whereby residents could contribute to one or more influenza seasons if they resided in a nursing home across multiple seasons. MethodsOur comparison of interest was marginalized vs privileged racial group membership measured as Black vs White race. We obtained influenza vaccination documentation from resident Minimum Data Set assessments from October 1 through June 30 of a particular influenza season. Nonparametric g-formula was used to estimate age- and sex-standardized disparities in vaccination, measured as the percentage point (pp) difference in the proportions of individuals vaccinated between Black and White nursing home residents within states and HRRs. ResultsThe study included 7,807,187 short-stay resident-seasons (89.7% White and 10.3% Black) in 14,889 nursing homes and 7,308,111 long-stay resident-seasons (86.7% White and 13.3% Black) in 14,885 nursing homes. Among states, the median age- and sex-standardized disparity between Black and White residents was 10.1 percentage points (pps) among short-stay residents and 5.3 pps among long-stay residents across seasons. Among HRRs, the median disparity was 8.6 pps among short-stay residents and 5.0 pps among long-stay residents across seasons. Conclusions and ImplicationsOur analysis revealed that the magnitudes of vaccination disparities varied substantially across states and HRRs, from no disparity in vaccination to disparities in excess of 25 pps. Local interventions and policies should be targeted to high-disparity geographic areas to increase vaccine uptake and promote health equity.

The geography of (un)reasonable suspicion: Rethinking causes of racial disparities in police stops

AbstractIn Illinois vs. Wardlow (2000), the U.S. Supreme Court ruled that presence in a “high‐crime” area is one factor that police can consider when establishing reasonable suspicion to justify a Terry stop. Some legal scholars argue that through this decision the Court propagated inequity in police stops by setting a lower evidentiary standard for establishing reasonable suspicion in neighborhoods with greater numbers Black residents, which are more likely than White neighborhoods to be considered crime hot spots. To assess these claims, I analyze pedestrian stop data from the Chicago Police Department for the years 2016 and 2017. Using spatial regression techniques, I evaluate relationships between neighborhood measures of Black disadvantage, police stop justifications, and “hit rates” of stops. The results suggest that reasonable suspicion is uniquely constructed in disadvantaged Black neighborhoods but that this does not result in significantly different enforcement rates. Based on these results, I argue that policing scholars must reconsider sources of inequity in policing and, in particular, consider the role of the law in shaping these outcomes.

The Association of Structural Fires With Heating Complaints and Race in New York City.

The devastating fire on January 9, 2022, led to the death of 8 children and 9 adults in New York City's Bronx borough. Previous reports have suggested that heating complaints in low socioeconomic Black/Latinx communities are frequently ignored. This trend suggests the existence of housing inequities and landlord negligence, which may lead to higher rates of residential fires in the Bronx and other low-income neighborhoods. However, this assertion has yet to be scientifically investigated. Two datasets (New York City Open Data Portal Fire Incident Dispatch and 311 Heat/Hot Water Complaints) were merged to determine the frequency of heating complaints and structural fires per month among community districts in New York City between 2017 and 2022. The primary outcome was structural fires per month which was modeled using a mixed effects multivariable regression allowing random intercepts for individual community districts. Within New York City's 59 community districts, 3,877 heating complaints were filed against 3,989 structural fires during the study period. The mixed effects model demonstrated a significant relationship between heat complaints and frequency of structural fires (coefficient 0.013, 95% confidence interval 0.012-0.014, P < .001). For the decennial census year 2020, the mixed effects model demonstrated a significant association between heat complaints and proportion of non-Hispanic, Black residents (coefficient 0.493, 95% confidence interval 0.330-0.657, P < .001). This highlights a trend in marginalized racial/ethnic communities, where unresolved heating complaints may force residents to resort to dangerous heating practices, inadvertently leading to fires and morbidity/mortality.

Demographic and Geographic Characterization of Excess Mortality During the COVID-19 Pandemic in Baltimore City, Maryland, March 2020 to March 2021.

Estimates of excess mortality can provide insight into direct and indirect impacts of the coronavirus disease 2019 (COVID-19) pandemic beyond deaths specifically attributed to COVID-19. We analyzed death certificate data from Baltimore City, Maryland, from March 1, 2020, to March 31, 2021, and found that 1,725 individuals (95% confidence interval: 1,495, 1,954) died in excess of what was expected from all-cause mortality trends in 2016-2019; 1,050 (61%) excess deaths were attributed to COVID-19. Observed mortality was 23%-32% higher than expected among individuals aged 50 years and older. Non-White residents of Baltimore City also experienced 2 to 3 times higher rates of excess mortality than White residents (e.g., 37.4 vs. 10.7 excess deaths per 10,000 population among Black residents vs. White residents). There was little to no observed excess mortality among residents of hospice, long-term care, and nursing home facilities, despite accounting for nearly 30% (312/1,050) of recorded COVID-19 deaths. There was significant geographic variation in excess mortality within the city, largely following racial population distributions. These results demonstrate the substantial and unequal impact of the COVID-19 pandemic on Baltimore City residents and the importance of building robust, timely surveillance systems to track disparities and inform targeted strategies to remediate the impact of future epidemics.