Separate but Unequal: Alcohol Outlets As an Indicator of Systemic Racism and the Health Risks of Segregation

Background. According to Healthy People 2020, health disparities arise from intentional or unintentional discrimination that reinforces social disadvantage and vulnerability. Explanations of the mechanisms that give rise to these health inequities often focus on individual level factors like stress and allostatic load, rather than the fundamental societal level factor of structural or systemic racism. Contributing to the disproportionate reliance on individual-level explanations are the challenges of measuring or quantifying racism at a systemic level.

The purpose of this study is thus to investigate whether inequities in the structural environment, in this case concentrated alcohol outlet density, could serve as indicators of residential segregation and systemic racism. In so doing we aim to provide a way to establish contextual risk for negative health outcomes. Residential segregation by race/ethnicity is associated with increased risk of mortality, particularly for black residents. Overconcentration of liquor outlets has also been recognized as a risk factor for negative health outcomes, including violence, motor vehicle crashes, and liver conditions. The mechanism by which alcohol outlets are associated with or health, however, has been inadequately articulated, both theoretically and empirically. We attempt to bridge that gap by exploring whether alcohol outlets are overconcentrated in segregated neighborhoods with a greater than area average concentration of minority residents and, as such, function as an indicator of segregation and thus systemic racism.

Methods. Alcohol outlet addresses for the year 2014 were obtained from the Alabama Alcoholic Beverage Control Board and the Louisiana Office of Alcohol and Tobacco. Outlets were geocoded to 2010 census tracts and merged with American Community Survey (ACS) 2010-2014 5-year estimates of population and socioeconomic indicators. Local alcohol control policy was obtained from state regulatory agencies. Black isolation was calculated at the county level to operationalize area residential segregation. Multilevel generalized linear models were used to investigate correlates of off-sale outlet density. All models were fit using the Glimmix procedure in SAS v 9.4.

Results. We found a positive association between black isolation and outlet density. Within a county, tracts with a greater share of black residents had significantly higher outlet density. A single standard deviation increase in the percentage of black residents was associated with 12% [1.12 (1.09, 1.15)] increase in outlet density in wet counties but a 44% [1.44 (1.34, 1.54)] increase in dry counties. Further, we found that tract racial composition remained significantly associated with outlet density in damp counties even after controlling for poverty.

Implications. Neighborhoods with a greater share of black residents are more likely to have an overconcentration of liquor outlets, an important indicator of negative health outcomes. Future research will help more explicitly understand the links between segregation and health. Additionally, investigations exploring how county and city-level policies impact these relationships and spatial relationships between outlets and health outcomes will further improve our understanding of the impact of neighborhood segregation on health.