Background: Sundown towns, historically recognized for systematically excluding African Americans post-emancipation and persisting into the 20th century, shed light on a critical yet often overlooked aspect of racial relations in the United States. Similar to the Homeowners Loan Corporation (HOLC) Redlining maps, sundown town practices served as deliberate and violent strategies to maintain a rigid racial caste system and enforce residential segregation.

Objective: To use an interdisciplinary, mixed-methods conceptual framework to present sundown towns as a multilevel geospatial measure of structural racism.

Methods: a descriptive case study of sundown towns in Iowa, alongside multilevel regression geospatial modeling.

Findings: Analysis of the History and Social Justice Project Sundown Town Database revealed 48 locations in Iowa identified as possible, probable, or confirmed sundown towns. Examination of birth certificate data at the zip code-level from the Iowa Department of Public Health from 2016-2022 (n=213,516) revealed that birthing women racialized as Black and Indigenous faced an increased risk of adverse birth outcomes, including preterm births, low birthweight infants, and maternal mortality.

Conclusion: This study highlights the significance of sundown towns as indicators of structural racism and their association with adverse health outcomes, particularly among marginalized communities. These findings underscore the need for targeted interventions to address health disparities rooted in historical inequities.

Background

Black women in the US are two to three times more likely to die from pregnancy-related causes than white women, despite most of maternal deaths being preventable. Studies show that racism is a driver of these inequities. We hypothesized that scores on the Everyday Discrimination Scale (EDS) would correlate with poor maternal or infant health outcomes.

Methodology

People who gave birth at one of five hospitals in Massachusetts and identified as non-Hispanic Black (NHB) or non-Hispanic White (NHW) were invited to complete a survey between 7-16 weeks postpartum. We assessed health outcomes and scores on the EDS using linear or ordered logistic regression models.

Results

Between 2022 and 2024, 670 postpartum (339 NHB and 331 NHW) patients completed the survey. Experiences of discrimination were associated with poorer outcomes. As everyday racism scores increased, the odds of experiencing a loss or NICU stay increases (β=1.2; 95% CI: 1.0, 1.5 and β=1.3; 95% CI: 1.0, 1.6, respectively). NHB participants reported significantly more discrimination when asked how they identify with the following statements, "You receive poorer service than other people at restaurants or stores." (β=0.81; 95% CI: 0.48, 1.1) and "People act as if they are afraid of you." (β=1.2; 95% CI: 0.78, 1.6). NHB scored 0.28 (CI: 0.14, 0.41) points higher, on average, than NHW participants on the EDS.

Conclusions

Experiences of discrimination increased the odds of experiencing a loss or NICU admission. Racism and discrimination must be the focus of reducing maternal deaths in the US and eliminating inequities.

Introduction

Sickle cell disease (SCD) is under-researched, underfunded, and fraught with health disparities. The lasting impact of housing discrimination on neighborhood well-being and individual health is established, and we hypothesized that individuals living with SCD are disproportionately affected.

Methods

We linked ZIP code-level data from the TN SCD Surveillance Program (SCDC-TN), state newborn screening records, Rural-Urban Continuum Codes, and the 2022 American Community Survey. Maps of neighborhoods previously targeted by discriminatory housing policy, known as “redlining”, were used to identify affected ZIP codes. We evaluated associations with GIS mapping, chi-square tests, and logistic regression with odds ratios and 95% confidence intervals (CI).

Results

From 2008-2020, 600 individuals were born with SCD in TN (53% male, 98% Black, and 89% urban). In total, 32 of 785 (4%) ZIP codes in TN were previously redlined, all of which are urban. Overall, 32% (191 of 600) of newborns with SCD resided in redlined areas, compared to 11% of all births in TN (127,755 of 1,122,448; p<0.0001), and 8% (535,367 of 6,935,933) of the total population (p<0.0001). Births with SCD had 5.6 (CI: 4.7-6.6) times the odds of living in a redlined area compared to the general population.

Within 4 urban TN counties with ZIP codes subjected to redlining, the proportion of individuals with SCD living in redlined areas was higher than the general population (Shelby p<0.0001, Davidson p<0.0001, Hamilton p=0.0004, Knox p=0.0385).

Conclusion

Individuals with SCD are disproportionately affected by the lasting effects of housing discrimination, which may contribute to persistent health disparities.

Black people have been historically and systematically oppressed, and this oppression continues to shape their experiences and outcomes within healthcare systems. By acknowledging and examining these systemic issues, we can work towards developing more effective strategies to address racial inequities and improve healthcare outcomes for Black communities. Using Afro-pessimism as a framework can provide a critical lens through which to examine how systemic racism and anti-blackness antics contribute to inequalities that exist within modern American healthcare. It also offers the opportunity to explore disparate outcomes in medicine and health care systems experienced by Black bodies that lead to unexpected and premature deaths. Using this framework may help to counter and possibly reconcile the fallout of scientific racism that continues to infiltrate health care by providing ‘an analytical framework’ for Black oppression and a novel, weaponized language for blasting away at the silencing of Black suffering, Black trauma, Black despair, and Black depression.