Vulnerability or Resiliency? A Two-Wave Panel Analysis of Social Network Factors Associated with Glycemic Levels among Mexican Immigrants in the Bronx, NYC, Before and During COVID-19.

Latinos have high rates of type 2 diabetes mellitus (T2DM) yet are characterized as having health-promoting social networks. The impacts of COVID-19 on personal networks were complex, especially in urban areas with high proportion of immigrants such as the Bronx in NYC. Our objective was to test the extent to which network characteristics increase vulnerability or resiliency for glycemic control based on data gathered from Mexican-origin Bronx dwellers. We used two-wave panel study analyzing self-reported personal social networks (n=30participants; 600network members) and HbA1c levels via dried blood spots in 2019, before the COVID-19 pandemic, and in 2021, a time after initial lockdowns and when the pandemic was still ravaging the community of study. Regression models adjusted for individual-level variables including sociodemographic and health indicators (i.e., physical health including COVID-19 and mental health). We found that an increase in the proportion of network members with diabetes predicted an increase in participant's HbA1c levels from 2019 to 2021 (ß=0.044, p < 0.05). Also, a greater proportion of network members consuming "an American diet" in 2019 predicted a decrease in participant's HbA1c levels (ß=-0.028, p < 0.01), while a greater proportion of network members that encouraged participants' health in 2019 predicted an increase in participant's HbA1c levels (ß=0.033, p < 0.05). Our study sheds light on specific social network characteristics relevant to individual diabetes outcomes, including potential longitudinal mechanistic effects that played out at the peak of the COVID-19 crisis.

The Repellent Capacity against Sitophilus zeamais (Coleoptera: Curculionidae) and In Vitro Inhibition of the Acetylcholinesterase Enzyme of 11 Essential Oils from Six Plants of the Caribbean Region of Colombia.

The repellent capacity against Sitophilus zeamais and the in vitro inhibition on AChE of 11 essential oils, isolated from six plants of the northern region of Colombia, were assessed using a modified tunnel-type device and the Ellman colorimetric method, respectively. The results were as follows: (i) the degree of repellency (DR) of the EOs against S. zeamais was 20-68% (2 h) and 28-74% (4 h); (ii) the IC50 values on AChE were 5-36 µg/mL; likewise, the %inh. on AChE (1 µg/cm3 per EO) did not show any effect in 91% of the EO tested; (iii) six EOs (Bursera graveolens-bark, B. graveolens-leaves, B. simaruba-bark, Peperomia pellucida-leaves, Piper holtonii (1b*)-leaves, and P. reticulatum-leaves) exhibited a DR (53-74%) ≥ C+ (chlorpyrifos-61%), while all EOs were less active (8-60-fold) on AChE compared to chlorpyrifos (IC50 of 0.59 µg/mL). Based on the ANOVA/linear regression and multivariate analysis of data, some differences/similarities could be established, as well as identifying the most active EOs (five: B. simaruba-bark, Pep. Pellucida-leaves, P. holtonii (1b*)-leaves, B. graveolens-bark, and B. graveolens-leaves). Finally, these EOs were constituted by spathulenol (24%)/ß-selinene (18%)/caryophyllene oxide (10%)-B. simaruba; carotol (44%)/dillapiole (21%)-Pep. pellucida; dillapiole (81% confirmed by 1H-/13C-NMR)-P. holtonii; mint furanone derivative (14%)/mint furanone (14%)-B. graveolens-bark; limonene (17%)/carvone (10%)-B. graveolens-leaves.

Insights from a cross-sectional binational study comparing obesity among nonimmigrant Colombians in their home country and Colombian immigrants in the U.S.

BACKGROUND: Latinos in the United States (U.S.) represent a heterogeneous minority population disproportionally impacted by obesity. Colombians in the U.S. are routinely combined with other South Americans in most obesity studies. Moreover, most studies among Latino immigrants in the U.S. solely focus on factors in the destination context, which largely ignores the prevalence of obesity and contextual factors in their country of origin, and warrant transnational investigations. METHODS: Using 2013-17 data from the New York City Community Health Survey (NYC CHS, U.S.) and the National Survey of the Nutritional Situation (ENSIN, Colombia), Colombians that immigrated to the U.S. and are living in NYC (n = 503) were compared to nonimmigrant Colombians living in their home country (n = 98,829). Prevalence ratios (PR) for obesity (BMI ≥ 30 kg/m2) by place of residence were estimated using multivariable logistic regression adjusting for socio-demographic characteristics and daily consumption of sugar-sweetened beverages. RESULTS: The prevalence of obesity was 49% greater for immigrant Colombians living in NYC when compared to nonimmigrant Colombians living in in their home country (PR = 1.49; 95% CI 1.08, 2.07). Colombian immigrant men in NYC were 72% more likely to have obesity compared to nonimmigrant men living in their home country (PR = 1.72; 95% CI 1.03, 2.87). No significant differences were found in the adjusted models among women. CONCLUSIONS: Colombian immigrants in NYC exhibit a higher prevalence of obesity compared to their nonimmigrant counterparts back home and sex strengthens this relationship. More obesity research is needed to understand the immigration experience of Colombians in the U.S. and the underlying mechanisms for sex difference. Public health action focused on women in Colombia and both Colombian men and women immigrants in the U.S. is warranted to avert the long-term consequences of obesity.

Nosotros mismos nos estamos matando/We are the ones killing ourselves: Unraveling individual and network characteristics associated with negative dietary acculturation among Mexican Americans in New York City.

BACKGROUND: Research on negative dietary acculturation among Mexican-Americans has mostly focused on individual-level processes and has largely ignored the role of social networks. METHODS: This mixed-method study used an egocentric network approach and derived 1620 personal ties of self-identified Mexican adults in New York. 24-hour dietary recalls were used to derive a total Healthy Eating Index (HEI) and subscores. The qualitative portion generated narratives around who helps or hinders their efforts to eat healthfully. RESULTS: At the individual level, age at which participants migrated to the U.S. was negatively associated with total HEI (ß = -0.39, p < .01). An annual income below $30,000 was positively associated with total HEI (ß = 0.25, p < .05) and with HEI fruit subscores (ß = 0.25, p < .05). Acculturative stress was negatively associated with HEI fruit (ß = -0.29, p < .05) and refined grain subscores (ß = -0.34, p < .01). At the network level, the proportion of network members who consumed traditional Latino diets was negatively associated with total HEI and HEI refined grains subscores (ß = -0.39, p < .001; and ß = -0.23, p < .05; respectively). In contrast, the proportion of alters who lived in another country was positively associated with HEI dairy subscores (ß = 0.25, p < .05). Juxtaposing qualitative participants' visual representation of their total HEI scores with their lay interpretations of healthy and unhealthy eating matched public health messages of reducing sugar, red meat intake, and processed foods. However, participants felt that this could only be achieved through restriction rather than balance. Qualitative narratives also elucidated how dietary acculturation and income could help shape dietary quality in unexpected ways. CONCLUSIONS: This study found evidence of negative dietary acculturation and showcases the complex ways in which both individual- and network-level processes help shape dietary choices for Mexican-Americans.

The copita question: Exploring alcohol consumption among Latina women.

We explored whether Dominican women underreport alcohol consumption according to questionnaire wording and examined factors associated with their alcohol use through structured interviews in Spanish. We measured consumption with the word "alcohol" and with the common colloquialisms "copita/trago/vinito." We used logistic regressions to examine associations between alcohol consumption, demographics, and alcohol-related norms. Of 419 female participants, 411 completed alcohol-related questions. Most (n=343, 83.5%) were current drinkers and 88 (21%) reported having never consumed alcohol but also that they occasionally drink a "copita/trago/vinito." This indicates alcohol use is potentially underreported among Dominican women. Alcohol-related research should incorporate culturally sensitive language to improve accuracy.

Assessing the Health and Economic Impact of a Potential Menthol Cigarette Ban in New York City: a Modeling Study.

Menthol in cigarettes increases nicotine dependence and decreases the chances of successful smoking cessation. In New York City (NYC), nearly half of current smokers usually smoke menthol cigarettes. Female and non-Latino Black individuals were more likely to smoke menthol-flavored cigarettes compared to males and other races and ethnicities. Although the US Food and Drug Administration recently announced that it will ban menthol cigarettes, it is unclear how the policy would affect population health and health disparities in NYC. To inform potential policymaking, we used a microsimulation model of cardiovascular disease (CVD) to project the long-term health and economic impact of a potential menthol ban in NYC. Our model projected that there could be 57,232 (95% CI: 51,967-62,497) myocardial infarction (MI) cases and 52,195 (95% CI: 47,446-56,945) stroke cases per 1 million adult smokers in NYC over a 20-year period without the menthol ban policy. With the menthol ban policy, 2,862 MI cases and 1,983 stroke cases per 1 million adults could be averted over a 20-year period. The model also projected that an average of $1,836 in healthcare costs per person, or $1.62 billion among all adult smokers, could be saved over a 20-year period due to the implementation of a menthol ban policy. Results from subgroup analyses showed that women, particularly Black women, would have more reductions in adverse CVD outcomes from the potential implementation of the menthol ban policy compared to males and other racial and ethnic subgroups, which implies that the policy could reduce sex and racial and ethnic CVD disparities. Findings from our study provide policymakers with evidence to support policies that limit access to menthol cigarettes and potentially address racial and ethnic disparities in smoking-related disease burden.

A qualitative study on mixed experiences of discrimination and healthcare access among HIV-positive immigrants in Spain.

BACKGROUND: Immigrants are disproportionally impacted by HIV infection in Europe and in Spain. Immigrants are also identified as a vulnerable population during economic crises. Various socioeconomic barriers hinder HIV-positive immigrants from accessing healthcare services in the host country. As a result of the 2008 financial crisis, Spain has implemented multiple austerity measures, one of which was the enactments of Royal Decree Law (RDL) 16/2012 and Royal Decree (RD) 1192/2012 which abolished universal healthcare coverage. In this context, this study examined: 1) Participants' mixed experiences in accessing health care after the enactment of 2012 RDL and RD, and 2) Distress felt by the participants and their experiences as HIV-positive immigrants living in Spain. METHODS: Participants were recruited through a nongovernmental organization (NGO) during routine visits at the center. A total of 12 participants were interviewed to reach data saturation. Participants were HIV-positive immigrants living in Spain for 1 or more years, allowing for substantial experience with navigating the healthcare system. Thematic analysis was performed to identify common themes in participants' experiences living as HIV-positive individuals in Spain and in accessing healthcare. RESULTS: Four primary themes were identified. The primary systemic barrier to accessing health care encountered by participants was the inability to fulfill the requirement of having proof of registration in an Autonomous Community for the required time period, thus not being able to apply for a public health insurance card and utilize free care services. Participants identified a positive impact of third party (NGO, social worker, friend/family member) guidance on their experience of applying for a public health insurance card. Participants expressed experiencing emotional or physical (eg, side effects of medication) distress in adapting to life as HIV-positive individuals. Participants also identified experiencing discrimination while living as HIV-positive immigrants in Spain. CONCLUSIONS: HIV-positive immigrants are underserved in Spain. They encounter systemic barriers while accessing healthcare services, and experience fear and/or discrimination. The study underscores the role of NGOs in helping HIV-positive immigrants navigate the healthcare system. More research is needed on comprehensive approaches to address healthcare needs of HIV-positive immigrants in Spain.

Late HIV diagnosis among immigrants in Spain vs. native-born Spaniards, 2010-15.

BACKGROUND: In 2012, the central government of Spain enacted Royal Decree-Law (RDL) 16/2012 and Royal Decree (RD) 1192/2012, which abolished universal healthcare coverage, thus limiting access to care for undocumented immigrants. Free health care was also no longer granted to anyone who has never been employed. In this context, this study investigated the prevalence of late HIV diagnoses (LHDs) among immigrants living in Spain vs. native-born Spaniards. METHODS: Data (n = 5943) from the 2010 to 2015 Cohort of the Spanish AIDs Research Network were used, including HIV-positive and antiretroviral therapy (ART)-naïve patients throughout Spain. Multivariate logistic models were fitted to compare the prevalence of LHD among the groups, adjusting for covariates. RESULTS: The prevalence of LHD in the total sample was 39.5%. Compared with native-born Spaniards (n = 4445), immigrants (n = 1488) were more likely to have LHD (37.4% vs. 45.7%, respectively; P < 0.001). Multivariate analysis showed that the prevalence ratio of LHD among immigrants vs. native-born Spaniards was 1.15 [95% confidence interval (CI), 1.02-1.28], after adjusting for covariates. This disparity widened from 2010 to 2011 (APR = 1.14, 95% CI, 1.02-1.29) to 2012-15 (APR = 1.28, 95% CI, 1.17-1.39), although the change was not statistically significant. CONCLUSIONS: Immigrants in Spain had a higher risk of LHD compared with native-born counterparts. LHD is an important healthcare marker due to the positive benefits of early HIV diagnosis, including prevention, improvements in health outcomes and decreases in overall cost of treatment. More research is needed on the causes of the disparity and potential social and policy interventions to reduce the prevalence of LHD among immigrants.

Promoting Health from the Pulpit: A Process Evaluation of HIV Sermons to Reduce HIV Stigma and Promote Testing in African American and Latino Churches.

Embedding health messages into sermons is a potentially valuable strategy to address HIV and other health disparities in churches that predominantly serve racial and ethnic minorities. This study explores implementation of an HIV sermon as part of a multi-component intervention in three churches (Latino Catholic, Latino Pentecostal, and African American Baptist) in high HIV prevalence areas of Los Angeles County, California. Clergy were given an HIV sermon guide that included local public health data, stigma reduction cues, HIV testing messages, and a sample sermon. Findings are based on a process evaluation (i.e., reach, dose delivered, fidelity, and implementation) and in-depth content analysis to explore HIV frames and messages used by clergy. Sermons were audio-recorded, transcribed verbatim, and coded using an inductive approach. Complementary data were collected through systematic observation. Overall, five clergy delivered nine HIV sermons to majority African American or Latino audiences. On average, 174 congregants were reached per sermon. We found large variation in fidelity to communicating key HIV messages from the sermon guide. While promoting HIV testing from the pulpit seemed viable and acceptable to all the participating clergy, fewer embedded explicit stigma reduction cues. Most spoke about HIV using compassionate and non-judgmental terms, however, issue framing varied across clergy. Structured training of clergy may be necessary to implement the more theoretically driven stigma reduction cues included in the sermon guide. More research is needed on the viability and acceptability of embedding specific health promotion messages into sermons.

National Trends in Food Insecurity and Congregation-Based Food Provision between 1998 and 2012.

Food insecurity has been a persistent problem in the U.S., and yet over the past three decades, federally funded food programs have become more restrictive. Scholars and policymakers have inquired whether the nonprofit sector is increasing its food provision activities to address this unmet need. This study analyzes data from the U.S. Census and a nationally representative survey of religious congregations in the U.S. to examine trends in food insecurity and congregation-based food provision between 1998 and 2012. The objective of the study is to investigate the extent to which congregation-based food provision fluctuated with national food insecurity prevalence for the overall population, and for subgroups vulnerable to this condition. Results show an over-time correspondence between the prevalence of food-insecure households and the prevalence of congregations that provide food. Parallel patterns are observed between food insecurity in disproportionately affected subpopulations (e.g., African-Americans and immigrants) and food provision in the congregations likely to serve those households. These findings indicate that congregations are helping meet the needs of food-insecure households. However, research suggests that congregations and nonprofits are not an adequate substitute for federally funded programs. Policy recommendations include expanding access to federally funded programs like the Supplemental Nutrition Assistance Program (SNAP) to more immigrants and other groups vulnerable to food insecurity, as well as providing more systematic financial or federal support and quality control of congregation-based efforts.

Racial/ethnic differences in perception of need for mental health treatment in a US national sample.

PURPOSE: To resolve contradictory evidence regarding racial/ethnic differences in perceived need for mental health treatment in the USA using a large and diverse epidemiologic sample. METHODS: Samples from 6 years of a repeated cross-sectional survey of the US civilian non-institutionalized population were combined (N = 232,723). Perceived need was compared across three non-Hispanic groups (whites, blacks and Asian-Americans) and two Hispanic groups (English interviewees and Spanish interviewees). Logistic regression models were used to test for variation across groups in the relationship between severity of mental illness and perceived need for treatment. RESULTS: Adjusting statistically for demographic and socioeconomic characteristics and for severity of mental illness, perceived need was less common in all racial/ethnic minority groups compared to whites. The prevalence difference (relative to whites) was smallest among Hispanics interviewed in English, -5.8% (95% CI -6.5, -5.2%), and largest among Hispanics interviewed in Spanish, -11.2% (95% CI -12.4, -10.0%). Perceived need was significantly less common among all minority racial/ethnic groups at each level of severity. In particular, among those with serious mental illness, the largest prevalence differences (relative to whites) were among Asian-Americans, -23.3% (95% CI -34.9, -11.7%) and Hispanics interviewed in Spanish, 32.6% (95% CI -48.0, -17.2%). CONCLUSIONS: This study resolves the contradiction in empirical evidence regarding the existence of racial/ethnic differences in perception of need for mental health treatment; differences exist across the range of severity of mental illness and among those with no mental illness. These differences should be taken into account in an effort to reduce mental health-care disparities.

Segmented Assimilation: An Approach to Studying Acculturation and Obesity Among Latino Adults in the United States.

Segmented assimilation theory posits that immigrants experience distinct paths of assimilation. Using cluster analysis and data from the National Latino and Asian American Survey, this study sought to apply this theory in relation to obesity among Latinos. Four clusters emerged: a "second-generation classic," a "third-generation classic," an "underclass," and a "segmented assimilation" pattern. In analyses controlling for sociodemographic confounders (eg, age), second-generation classic individuals had higher odds of obesity (odds ratio = 2.70, 95% confidence interval = 1.47-4.93) relative to the segmented pattern. Similarly, third-generation classic individuals had higher odds of obesity (odds ratio = 3.23, 95% confidence interval = 1.74-6.01) compared with segmented assimilation individuals.

Latino Immigrants, Acculturation, and Health: Promising New Directions in Research.

This article provides an analysis of novel topics emerging in recent years in research on Latino immigrants, acculturation, and health. In the past ten years, the number of studies assessing new ways to conceptualize and understand how acculturation-related processes may influence health has grown. These new frameworks draw from integrative approaches testing new ground to acknowledge the fundamental role of context and policy. We classify the emerging body of evidence according to themes that we identify as promising directions--intrapersonal, interpersonal, social environmental, community, political, and global contexts, cross-cutting themes in life course and developmental approaches, and segmented assimilation--and discuss the challenges and opportunities each theme presents. This body of work, which considers acculturation in context, points to the emergence of a new wave of research that holds great promise in driving forward the study of Latino immigrants, acculturation, and health. We provide suggestions to further advance the ideologic and methodologic rigor of this new wave.

Effects of a Pilot Church-Based Intervention to Reduce HIV Stigma and Promote HIV Testing Among African Americans and Latinos.

HIV-related stigma and mistrust contribute to HIV disparities. Addressing stigma with faith partners may be effective, but few church-based stigma reduction interventions have been tested. We implemented a pilot intervention with 3 Latino and 2 African American churches (4 in matched pairs) in high HIV prevalence areas of Los Angeles County to reduce HIV stigma and mistrust and increase HIV testing. The intervention included HIV education and peer leader workshops, pastor-delivered sermons on HIV with imagined contact scenarios, and HIV testing events. We surveyed congregants at baseline and 6 month follow-up (n = 1235) and found statistically significant (p < 0.05) reductions in HIV stigma and mistrust in the Latino intervention churches but not in the African American intervention church nor overall across matched African American and Latino pairs. However, within matched pairs, intervention churches had much higher rates of HIV testing (p < 0.001). Stigma reduction and HIV testing may have synergistic effects in community settings.

Predictors of HIV-related stigmas among African American and Latino religious congregants.

OBJECTIVES: To inform church-based stigma interventions by exploring dimensions of HIV stigma among African American and Latino religious congregants and determining how these are related to drug addiction and homosexuality stigmas and knowing someone HIV-positive. METHOD: In-person, self-administered surveys of congregants 18+ years old across 2 African American and 3 Latino churches (n = 1,235, response rate 73%) in a western U.S. city with high HIV prevalence. Measures included 12 items that captured dimensions of HIV stigma, a 5-item scale that assessed attitudes toward people who are addicted to drugs, a 7-item scale assessing attitudes toward homosexuality, and questions regarding sociodemographics and previous communication about HIV. RESULTS: Of the survey participants, 63.8% were women, mean age was 40.2 years, and 34.4% were African American, 16.8% were U.S.-born Latinos, 16.0% were foreign-born, English-speaking Latinos, and 32.9% were foreign-born, Spanish-speaking Latinos. Exploratory and confirmatory factor analyses identified 4 dimensions of HIV stigma: discomfort interacting with people with HIV (4 items, α = .86), feelings of shame "if you had HIV" (3 items, α = .78), fears of rejection "if you had HIV" (3 items, α = .71), and feelings of blame toward people with HIV (2 items, α = .65). Across all dimensions, after controlling for sociodemographic characteristics and previous communication about HIV, knowing someone with HIV was associated with lower HIV stigma, and greater stigma concerning drug addiction and homosexuality were associated with higher HIV stigma. CONCLUSIONS: Congregation-based HIV stigma reduction interventions should consider incorporating contact with HIV-affected people. It may also be helpful to address attitudes toward drug addiction and sexual orientation. (PsycINFO Database Record

The Power of Place: Social Network Characteristics, Perceived Neighborhood Features, and Psychological Distress Among African Americans in the Historic Hill District in Pittsburgh, Pennsylvania.

African American neighborhoods have been historically targeted for urban renewal projects, which impact social composition and resident's health. The Hill District in Pittsburgh, PA is such a neighborhood. This research sought to investigate the extent to which social networks and perceived neighborhood social cohesion and safety were associated with psychological distress among residents in an African American neighborhood undergoing urban renewal, before the implementation of major neighborhood changes. Findings revealed a modest, significant inverse association between social network size and psychological distress (ß = -0.006, p < .01), even after controlling for age, employment, education, and income. Perceived neighborhood safety predicted decreased psychological distress (ß = -1.438, p < .01), but not social cohesion, which is consistent with past research. Findings suggest that social networks protect against psychological distress, but neighborhood perceptions are also paramount.

Unraveling Familism and Depressive Symptoms among Dominican Women: A Multidimensional Analysis.

Familism is a multidimensional construct that includes familial support. However, limited research examines whether the sub-components of familism equally contribute to mental health and whether familism protects against depression beyond social support. To address these gaps, we test associations between the multidimensional components of familism (familial support, familial obligations, family as referents) and social support with depressive symptoms among immigrant Dominican women in New York City. We tested associations between the multidimensional components of familism, specifically, familial support, familial obligations, and family as referents (Sabogal et al., 1987), as well as social support, with depressive symptoms among 419 women. Multiple regression analysis indicated that whereas familial support predicted decreases in depressive symptoms (ß = - 0.15), family obligations, and family as referents did not. However, only social support predicted decreased depressive symptoms (ß= - 0.18) when accounting for covariates and familism subscales. Controlling for covariates, age predicted decreased depressive symptoms (ß = - 0.19), whereas self-rated poor health exhibited the inverse effect (ß = 0.17). These findings highlight the need for a nuanced understanding of familism, social support, and the association of cultural and demographic values on Latina mental health. These results illustrate the need for further analysis of social support and the multiple components of the familism construct.

South-to-South parental migration patterns and excess weight among children: Insights from a national cross-sectional study in Colombia.

BACKGROUND: Evidence from Latin America suggests that children embedded in South-to-North migrant networks (i.e. relatives who live abroad, typically in the United States) are at increased risk of excess weight. It is unclear if the same findings apply to children embedded in Latin American intraregional migration or South-to-South migration networks. OBJECTIVE: To compare excess weight among Colombian children embedded in South-to-South migration networks (n = 334) to children with non-migrant parents (n = 4272) using Colombia's 2015 National Survey of the Nutritional Situation. METHODS: Prevalence ratios (PRs) for excess weight (BMI z-score ≥1) by parent migration history were estimated using weighted multivariable logistic regression adjusting for demographics, child behaviours, community and household indicators, including household food insecurity. RESULTS: Most migrant parents returned to Colombia from Venezuela (84%) and reported higher household food insecurity rates than non-migrant parents (59% versus 32%). Models excluding household food insecurity showed that excess weight among children with migrant parents was 51% lower (PR = 0.49; 95% CI 0.25, 0.98) than among children with non-migrant parents. After adjustment for household food insecurity, no statistically significant differences were found. CONCLUSION: Colombian children with return migrant parents from Venezuela experienced less excess weight than children with non-migrant parents, but higher rates of food insecurity in migrant households might partially explain this difference. This study calls attention to two serious public health concerns for Colombian children-those who have excess weight and those who lack sufficient food, particularly among migrant returnees (a situation that may have worsened since the COVID-19 pandemic).