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 Los Angeles. Our findings indicated that declines were steeper in census tracts where alcohol outlets were closed. Nevertheless, it is possible that independent events, such as targeted HIV prevention efforts and STD control efforts may have also contributed to the decline. These may have facilitated the interruption of sexual networks associated with alcohol outlets (De et al., 2004
). A simultaneous dynamic relationship between physical structures (outlets) and social structures (community norms and behaviors) makes it impossible to exactly pinpoint whether the closure of alcohol outlets operates directly on sexual behaviors or through a norm-changing mechanism. It is clear however, that the riots were a seminal event that preceded the subsequent steeper decline in gonorrhea in affected tracts compared to non-damaged tracts.
Although we did obtain annual data on race/ethnicity, gender, and age of the denominator populations, and our models controlled for changes in the population, our SES measures were only from 1990, and our damage indicator was only for 1992. An important concern is that the census tends to undercount populations in low-income areas with high rates of minorities (Anderson & Fienberg, 2000
). However, the tendency to underreport gonorrhea and our geocode rate of 83% together are both likely to be even lower than a population undercount, making our annual estimates of gonorrhea rates conservative (Kirsch et al., 1998
; Rothenberg et al., 1980
). These biases in reporting and identifying gonorrhea cases are likely to be constant over time. Since our geocode rate was similar each year, our analysis of the relative changes in gonorrhea over time, rather than the absolute estimates, should be correct.
Another concern was the lack of information on when and if damaged building were repaired after the riots, making it impossible to discern the impact of damage over time. If buildings were repaired, it might explain why we found a negative association between damaged buildings and gonorrhea, as these would have represented new, potentially improved buildings rather than “broken windows”.
Activities related to efforts to preventing closed alcohol outlets from re-opening subsequent to the civil unrest may also have resulted in other unmeasured community changes that could influence continued sexual risk taking among populations in affected areas. Potential unmeasured examples of this include community and police efforts to close down crack houses, shooting galleries and open air drug markets, greater police presence and enforcement in these neighborhoods that also discouraged prostitution and disrupted drug markets (Operation Cul–De–Sac), and better parental and community monitoring of adolescents and young adults during high risk times (3–6 pm).
Other possibilities might include greater police presence and enforcement in these neighborhoods that also discouraged high-risk behaviors. Although 12,000 persons were arrested for rioting and looting during this period, most were quickly released, so it is unlikely that the incarceration of large number of high-risk residents could have explained subsequent continued declines in community rates of gonorrhea.
Alcohol outlets have historically been considered nuisances in residential neighborhoods. In particular, the presence of community activists who had the closure of alcohol outlets at the top of their agenda made a difference in preventing dozens of businesses that had previously been problematic from reopening as alcohol outlets. In the short-term, the combined community activism and the obvious physical neighborhood change reduced overt social disorder, like public drinking and loitering youths. Curfews, initial successes in preventing the reopening of closed outlets, and other control measures after the civil unrest may have given a boost to what has been called “collective efficacy,” with people more willing to exert even greater informal social controls, knowing that there might be more back-up from the law enforcement infrastructure. There was also a subsequent optimism, in that several high profile efforts to “Rebuild LA” occurred in the aftermath of the civil unrest. Although it is not possible to tease out which of these changes might be most responsible for the decline in gonorrhea, each component is likely to have made an important contribution.
One final concern with our spatial analysis was the use of census tracts which are arbitrarily related to the clustering of alcohol outlets. The absolute availability of alcohol might not be best captured by a census tract analysis even accounting for spatial autocorrelation. Also the choice of the appropriate range for assessing spatial autocorrelation is not clear.
Although the LA civil unrest changed both the physical and social structures of affected communities, the loss of alcohol outlets was particularly salient. The contribution of outlet decline to reductions in gonorrhea cases appears significant and it is also possible that other outcomes may be affected as well, including domestic violence, assaults, injuries, and traffic fatalities, and even AIDS cases. While future studies can investigate these possibilities, the findings we have support the importance of continuing controls and limits on alcohol outlet density.