Defining Sundown Towns
The legacy of sundown towns—any organized jurisdictions that employed violence to enforce exclusionary and segregation policies against Black, Indigenous, and People of Color (BIPOC)—is not merely a concealed relic of a racist past but a persistent force perpetuating structural inequities that contribute to ongoing health disparities. Because they are often seen as shameful and concealed from American history, sundown towns—most prevalent in the Midwest and the West—are frequently excluded from discussions of places with a legacy of structural violence and segregation. Incorporating measures of sundown town histories into health services research (HSR) will enable research, policy and interventions to identify the enduring upstream root causes of health inequities, even in rural and data restricted areas.
Sundown town practices varied: some used vulgar signs or sirens at dusk to warn BIPOC communities to leave, while others enforced exclusion through national vigilance groups like the Ku Klux Klan (KKK) or locally organized lynching mobs and racial massacres. These towns were intentionally designed to create segregated environments enforced through violence, fear, and racial capitalism, effectively limiting access to all structural and social determinants of health. Previous research has used Jim Crow laws in the South and exclusionary Home Owners' Loan Corporation (HOLC) redlining maps as proxies of structural racism, demonstrating an enduring impact of racial injustices on contemporary health outcomes. However, a limitation of this work is that Jim Crow laws were mandated in the South, and redlining policies focused on urban areas with denser populations, leaving rural agricultural regions like the Midwest mostly invisible and missing the nuance of the unique displays of cultural violence and segregation.
Understanding the Role of Sundown Towns in Health
Today, while there is robust literature examining how racist legacies, urban planning, and financial institutions have contributed to health inequities, it is crucial to explore additional approaches that include some of the most rural and homogenous places, such as those in the Midwest. As a medical sociologist utilizing critical social theories and mixed methodologies, I argue that capturing and measuring the enduring impact of these practices requires developing new, interdisciplinary, and qualitatively informed measures of structural inequity that can illuminate the social, historical, and structural factors driving disparities in health outcomes. My work employs a multi-faceted approach, including the collection of historical data, oral histories, and the integration of geographical information systems (GIS) to map areas with sundown town legacies within their historical contexts. Such comprehensive measures will enable the field to better examine the correlation between past racial exclusion and present-day health outcomes.
The economic disenfranchisement, exclusionary practices, and racialized economic structures created by sundown towns have contributed to socioeconomic disparities directly linked to health outcomes. As a result, former sundown towns may have higher quality health care facilities compared to racially diverse or economically disadvantages areas. HSR could explore how these inequities persist in the form of biased medical care, disparities in health insurance coverage, and differences in healthcare utilization rates. It can also examine how the legacy of sundown towns influences the trust of communities historically made vulnerable, potentially affecting patient engagement, adherence to treatment and preventative care practices.
In recent years, sundown towns have surfaced in academic discussions; however, these discussions are limited but wide ranging exploring the enduring legacy in relation to economic inequality, racial diversity, COVID-19 risk, and prenatal birth outcomes. Acknowledging the multi-generational, ecological impact of sundown towns on public health and HSR fosters a more community-engaged and holistic understanding of the root causes of contemporary health disparities and inequities. Furthermore, the history of sundown towns challenges researchers and policymakers to consider the socio-historical context of communities rather than solely focusing on individual behaviors or genetic predispositions. This shift in perspective is vital for crafting policies that not only address immediate health care needs but also dismantle the systemic barriers that perpetuate health inequities.
How the Study of Sundown Towns Can Strengthen Policy Implications and Interventions
HSR can play a crucial role in proposing reparative policies that acknowledge the historical wrong of sundown towns. This could include targeted investment in health care infrastructure, education and economic development in communities that have suffered from the legacy of racial exclusion and exploitation. Here are a few ways that health services researchers can develop targeted policy interventions that address these historical injustices.
- Redistribution of Health Resources: Advocating for equitable distribution of health care facilities and resources to address gaps created by exclusionary practices.
- Community-partnered Interventions: Develop health interventions that are culturally sensitive and specifically tailored to the unique, intersectional needs of communities that have long been excluded from economic and social opportunities. These interventions should be co-designed with community members to ensure they address the specific historical and present-day challenges faced by these groups.
- Addressing Social and Structural Determinants of Health: Conduct research in underexplored areas to examine how economic policies and practices—such as those related to housing, employment, and education—linked to sundown towns have shaped diversity, economic opportunities, and health outcomes. This research should highlight how aligning health policies with broader social and economic strategies can more effectively address these structural determinants.
Given this context, incorporating measures of sundown towns into HSR is both urgent and essential for a comprehensive understanding of how historical and structural factors shape contemporary health disparities. This approach encourages the field to move beyond viewing the United States' history of racial violence and segregation as affecting only groups racialized as BIPOC. By recognizing that these injustices have geo-structural and cultural impacts that span generations and extend beyond racialized categories, we can transform the lessons of past injustices into actions that promote a healthier, more informed, and inclusive future for all.