In this essay we examine three competing causal interpretations of racial disparities in health. The first approach views race as a biologically meaningful category and racial disparities in health as reflecting inherited susceptibility to disease. The second approach treats race as a proxy for class and views socioeconomic stratification as the real culprit behind racial disparities. The third approach treats race as neither a biological category nor a proxy for class, but as a distinct construct, akin to caste. We point to historical, political, and ideological obstacles that have hindered the analysis of race and class as codeterminants of disparities in health.

More than a decade ago Vicente Navarro drew attention to the apparent tension between a race-based account of health disparities versus the class-based view. 1 Although (as Navarro wryly noted) the United States has classes as well as races, data on health disparities are seldom presented along both axes of stratification. The U.S. government is one of the few developed Western nations that does not routinely report health statistics by class. 2 For example, whereas long-term time series are readily available on the U.S. black-white life expectancy gap, there is a dearth of corresponding data on trends in class disparities, whether measured by income, occupation, or educational attainment.

In this paper we critically dissect the public and academic discourses on health disparities. We aim to show how hidden tensions between a race-based as opposed to a class-based account of health disparities closely parallel the longstanding tensions within other policy arenas (for example, affirmative action in hiring and college admissions). We first lay out the three prevailing interpretations of race-based health disparities within U.S. society. Next we present an argument about how the race-based account of disparities has been historically manipulated to suppress class-based discourse in the United States. We then sketch out the policy implications of adopting the view that emphasizes both class and race as codeterminants of disparities in health.

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