The Unique Impact of Abolition of Jim Crow Laws on Reducing Inequities in Infant Death Rates and Implications for Choice of Comparison Groups in Analyzing Societal Determinants of Health

摘要

Objectives. We explored associations between the abolition of Jim Crow laws (i.e., state laws legalizing racial discrimination overturned by the 1964 US Civil Rights Act) and birth cohort trends in infant death rates. Methods. We analyzed 1959 to 2006 US Black and White infant death rates within and across sets of states (polities) with and without Jim Crow laws. Results. Between 1965 and 1969, a unique convergence of Black infant death rates occurred across polities; in 1960 to 1964, the Black infant death rate was 1.19 times higher (95% confidence interval [CI]?=?1.18, 1.20) in the Jim Crow polity than in the non–Jim Crow polity, whereas in 1970 to 1974 the rate ratio shrank to and remained at approximately 1 (with the 95% CI including 1) until 2000, when it rose to 1.10 (95% CI?=?1.08, 1.12). No such convergence occurred for Black–White differences in infant death rates or for White infants. Conclusions. Our results suggest that abolition of Jim Crow laws affected US Black infant death rates and that valid analysis of societal determinants of health requires appropriate comparison groups. Surprisingly little research has quantified the health impact of the abolition of Jim Crow legislation, that is, state laws legalizing racial discrimination overturned by the 1964 US Civil Rights Act (78 Stat 241). 1–6 The 4 extant empirical population-based investigations, however, provide suggestive evidence of improvements in health among Black Americans and decreases in health inequities between Blacks and Whites. 7–10 Far from a matter of historical interest only, the contemporary significance of whether abolition of Jim Crow laws had any health impact is both substantive and methodological. At issue is understanding not only determinants and consequences of trends in US racial/ethnic health inequities within and across generations 11,12 but also the assumptions underlying such analyses. In particular, conceptualizing Jim Crow legislation as a political determinant of health shifts the focus from “race/ethnicity” to race relations as a causal exposure, thereby raising an important question from a counterfactual standpoint: should contrasts be within or across the racial/ethnic groups defined by these race relations? 13–15 This question of who should be contrasted adds another dimension to current methodological discussions on quantifying health inequities, which chiefly emphasize which effect measures should be used (e.g., relative vs absolute difference). 16–18 We chose to focus on the abolition of Jim Crow laws on a priori theoretical grounds, because it is precisely the type of epochal event 2–6 that, according to leading social epidemiological and political sociology theories, should produce clear-cut period and cohort effects. 19–23 The abolition of Jim Crow legislation was a critical turning point in the process of formal political incorporation of Black Americans into the US society, 3–6 whereby the political incorporation of socially defined groups refers not only to their political rights and political participation as citizen members of an electorate but also to their politically gaining the capacity and agency to advance fulfillment of their human rights. 4–6,23–27 To date, however, scant research has explicitly examined the health impact of political incorporation 22 ; 2 notable exceptions—a study addressing post-Apartheid policies in South Africa 28 and a study focusing on the extension versus denial of political rights to women in 61 countries 29 —showed that political incorporation reduced health inequities. The case of Jim Crow is thus not only important in its own right but potentially can provide useful substantive and methodological insights relevant to assessing the health impacts of current efforts to promote political incorporation (e.g., the extension of voting rights to migrants 26,30 ). We selected infant death as the “outcome” because it is a widely used indicator of population health that is highly sensitive to living conditions and access to medical technology during pregnancy and the first year of life and is also reflective of mothers’ cumulative health status before and after conception. 31–33 For our comparisons, we took the novel step of contrasting outcomes between what we term Jim Crow and non–Jim Crow polities. These entities, defined by their politics as opposed to their geography, 22,23 respectively comprised sets of states that did and did not have laws legalizing racial discrimination overturned by the 1964 US Civil Rights Act, regardless of geographic location (i.e., these states were not restricted solely to the US South). 1 We assessed birth cohort effects and trends in Black and White infant death rates and differences in these rates, taking into account state, county, and income effects, thereby enabling a direct test of the role of political incorporation in reducing health inequities.