Alcohol outlets, gonorrhea, and the Los Angeles civil unrest: A longitudinal analysis

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Abstract

This study tests the effect of neighborhood changes on gonorrhea rates. Prior studies that indicate gonorrhea rates are associated with alcohol outlet density and neighborhood deterioration have been cross-sectional and cannot establish causality. After the 1992 Civil Unrest in Los Angeles, 270 alcohol outlets surrendered their licenses due to arson and vandalism thus providing a natural experiment. We geocoded all reported gonorrhea cases from 1988 to 1996 in LA County, all annually licensed alcohol outlets, and all properties damaged as a result of the civil unrest. We ran individual growth models to examine the independent effects of changes in alcohol outlets and damaged buildings on gonorrhea. The individual growth model explained over 90% of the residual variance in census tract gonorrhea rates. After the civil unrest, a unit decrease in the number of alcohol outlets per mile of roadway was associated with 21 fewer gonorrhea cases per 100,000 (p<.01) in tracts affected by the Unrest compared to those not affected. Neighborhood alcohol outlets appear to be significantly associated with changes in gonorrhea rates. The findings suggest that efforts to control sexually transmitted diseases, including gonorrhea and HIV, should address contextual factors that facilitate high-risk behaviors and disease transmission

Introduction

The world in which we live is a complicated ecosystem in which small changes in one seemingly distant component can affect other facets of the system indirectly. When neighborhoods and communities are physically altered, many social changes and unintended consequences may follow. For example, Wallace et al. (Wallace, 1990; Wallace & Wallace, 1991) described how the closure of fire stations in parts of New York City led to neighborhood deterioration, community destruction, and the spread of HIV. DeCosas describes how the building of a dam in Ghana displaced villages and resulted in an epidemic of HIV because villagers who lost their farmlands, and thus their livelihoods, took up sex work as a means to survive (Decosas, 1995).

Neighborhood change, however, is usually more subtle or gradual than these examples, making the impact of the physical environment on our social behaviors hard to identify. In addition, because many socioeconomic and demographic groups in the United States exhibit substantial mobility (20% of United States residents moved within 1 year, between 1999 and 2000 (Census, 2000)), it can be particularly difficult to link health outcomes at the individual level to neighborhood conditions. Lastly, despite legal protections to ensure residential choice, differential access to housing loans and markets can make it difficult to disentangle individual and group preferences for community types from the impact of a neighborhood's physical and social structure on the individuals who live there (Fischer, 2003; Holloway, 1998; Massey & Denton, 1993; Squires, Friedman, & Saidat, 2002). Opportunities to understand the discreet effects of the environment may arise when sudden changes occur and subsequent events can be clearly attributed to those changes.

Such an opportunity arose in Los Angeles in 1992, when, in the aftermath of the trial of the four police officers accused of brutally beating Rodney King, several days of rioting, looting, and arson resulted in the closure of 270 alcohol outlets, 55 deaths, and nearly one billion dollars of property damage (Fig. 1). In addition, a community mobilization effort in South Central Los Angeles that had begun prior to the civil unrest in response to the crack cocaine epidemic (Karen Bass, 2004, personal communication) was refocused on preventing destroyed alcohol outlets from reopening (Grills, Bass, Brown, & Akers, 1996). The property destruction coupled with community efforts that resulted in new conditional use zoning laws made it more difficult to open an alcohol outlet. Placing a variety of new requirements on operating alcohol outlets reversed a trend of increasing alcohol outlets in Los Angeles County (Berestein, 1994; Kang, 1994).

Since peaking in 1992, there has been a 9% decrease in overall on-premise alcohol outlets in Los Angeles County and an 11% decrease in overall off-premise outlets through 2000 (California Alcohol Beverage Control). Eighteen percent of this decline was a direct result of civil unrest caused destruction of alcohol outlets. Community mobilization prevented at least 40 off-premise alcohol outlets from re-opening and many were forced to reopen in other locations (Robinson-Jacobs, 2002).

Previous research has linked the density of neighborhood alcohol outlets with a variety of negative health outcome including homicides, assault, motor vehicle fatalities, and gonorrhea rates (2000; Gorman & Speer, 1997; Gruenewald & Ponicki, 1995; Scribner, Cohen, & Farley, 1998; Scribner, Cohen, & Kaplan, 1999; Scribner, MacKinnon, & Dwyer, 1994). In addition, previous studies indicate that deteriorated neighborhoods characterized by boarded up homes have higher rates of gonorrhea, premature mortality, and premature mortality from homicide and heart disease (Cohen et al., 2000; Cohen, Farley, & Mason, 2003; Cohen et al., 2003). However, these studies have been cross-sectional so it is unclear if these associations are causal.

A combination of theories has been put forward to explain the various components of the complex social, economic, and environmental interactions involved in a potential causal relationship between alcohol outlet density and alcohol related outcomes like gonorrhea. In a study of sexual networks involved in a gonorrhea outbreak, a popular motel bar was found to be the most important linking factor for eight large sexual networks (De, Singh, Wong, Yacoub, & Jolly, 2004). Gruenewald and colleagues (Gruenewald, Treno, Nephew, & Ponicki, 1995) have promoted a theory of economic optimization to explain the “choice” of drinking venues (i.e., liquor stores versus bars) by various risk populations in terms of maximizing their demand for alcohol within economic and environmental constraints. Optimization theory explains why the drinking patterns of African Americans, the population at highest risk for gonorrhea, tend to be associated with off-premise liquor outlets, the type of outlet typically destroyed during the 1992 Civil Unrest. Treno, Alaniz, and Gruenewald, (2000) have extended optimization theory incorporating concepts of routine activities theory (Cohen & Felson, 1979) by demonstrating that African American and Hispanic drinking patterns associated with liquor stores results in drinking in less controlled environments (i.e., parties, special events, public places, and friend's houses). Presumably, it is in these environments that the greater risks of high risk sexual behavior and disease transmission occur, thus explaining the higher rate of gonorrhea associated with alcohol availability at local liquor stores. However, it should be noted that no research to support this final supposition has been conducted. Finally, race/ethnicity is also strongly associated with gonorrhea and STDs with African-Americans and Hispanics affected at rates 7–30 fold higher than Whites (Moran, Aral, Jenkins, Peterman, & Alexander, 1989). This large difference in disease prevalence has not been associated with any genetic predispositions (Aral, 1994; Ellen, Aral, & Madger, 1998; Garnett et al., 1996).

This paper investigates the temporal and geographic association between reported cases of gonorrhea and alcohol outlets and damaged buildings. On the one hand, if alcohol outlets are in the causal pathway of gonorrhea because they supply alcohol, which is associated with risky behaviors, we would expect declines in gonorrhea with their closure. On the other hand, if boarded up buildings signal social disorder and tolerance of deviant and high-risk behaviors, then an increase in gonorrhea should follow an increase in property damage.

The greatest numbers of reported gonorrhea cases tend to come from poor and minority communities (Cohen et al., 2000; Scribner et al., 1998). Since the poor and minority communities within our study area are composed of multiple contiguous census tracts, we expect that census tracts with high gonorrhea rates will be spatially clustered or spatially autocorrelated. Regression analyses involving spatially autocorrelated units can lead to inflation of the effect sizes resulting in Type 1 errors (Gruenewald, 2000). Consequently, our analysis includes a spatial regression model and a nuisance parameter to account for spatial error.

Section snippets

Sample description

The unit of analysis in this study was the census tract. The study includes 1652 census tracts in Los Angeles County from the 1990 US Census definitions, which represent a rich mix of race/ethnicity, socio-economic status and prevalence of gonorrhea. Of these, we excluded 159 tracts with a population less than 2700, and 12 unusual tracts that included ships-at-sea, group quarters and Universal Studios. As a result, the analysis sample included 1481 census tracts. Of the 1481 tracts, 420 tracts

Results

Table 1 summarizes the predictors used in the models and describes the demographic characteristics of the 1481 tracts in Los Angeles County. Among the tracts, the average number of off-premise alcohol outlets per road mile prior to the 1992 riot was 0.49, the average percent of off-premise liquor outlet licenses surrendered immediately after the riot was 3%, and the proportion of tracts that reported any damage due to the civil unrest was 28%.

Table 2 lists correlations between tract

Discussion

Our findings support the significant role of alcohol outlets, but not damaged buildings in the spread of gonorrhea. Although a plausible mechanism for alcohol outlets is their supply of a substance that is used to facilitate sex, alcohol outlets can facilitate other substance use by selling drug use paraphernalia (i.e. tobacco rolling papers that can be used for marijuana, clear tubing used to make crack cocaine pipes, single steel wool pads used to fashion crack cocaine pipe filters).

Limitations

Although our study is a longitudinal design, the data we have obtained are ecological and so there are several limitations that need to be recognized. The civil unrest and loss of outlets are closely intertwined and it is not possible to identify the precise mechanism of gonorrhea decline—whether due to community change in norms and tolerance for deviant behaviors or due to closure of alcohol outlets alone. The secular trend over this time period showed a decline in gonorrhea in all areas of

Acknowledgement

This study was funded by NICHD #R21HD42980, Drew/UCLA Project Export Center #P0MD000148, and Drew Core Infrastructure Development Grant #G12RR03026.

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