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The question is not: “Is race or class more important?”
  1. Paula Braveman
  1. Center on Social Disparities in Health, University of California, San Francisco, San Francisco, USA;

    Statistics from

    Discussions about links between race and class are not new, but a recent resurfacing in the USA of the flawed question about which is more important leads me to choose this topic. While race may draw more attention here than in some other nations, the hideous genocide in the Sudan and ugly racial/ethnic divisions in many other places as well suggest that this discussion may have some wider relevance.

    The issue of socioeconomic influences on health was marginalised in the USA until the Cold War ended. Since the early 1990s, there has been an opening for academic research on the mechanisms explaining class disparities in health. However, the opening in research has not been accompanied by major policy initiatives applying what is already known about how socioeconomic factors, particularly those experienced in childhood, constrain people’s opportunities to be healthy throughout the life course.

    Racism also has been a taboo topic. Awareness has been somewhat increased by recent reports from prestigious agencies, reviewing a large body of evidence showing systematic bias (probably largely unconscious) along racial/ethnic lines in health care delivery. Many public and private initiatives have been launched over the past decade, addressing racial/ethnic disparities in health care, most focusing on “cultural competence” by care providers as the remedy, sidestepping consideration of both structural racism and class.

    Recently, the US Congress discussed replacing initiatives on racial/ethnic disparities with targeting the economically disadvantaged, regardless of race. Although the acknowledgement of economic disadvantage is welcome, this would be an unfortunate move. It would take race and racism off the agenda, subsuming it under class. It also would play off people of colour against low income white people because resources would not be increased along with the widened scope. One recurring theme among proponents of this direction is that class is “more important” than race.

    Weighing race and class against each other is based on a false construct. Given the history of racism, even if all interpersonal racism were eliminated, the institutional structures that shape people’s opportunities in life from early childhood—for example, by determining their parents’ and their own educational and employment opportunities—are so powerful that we would continue to see huge racial/ethnic differences in many health outcomes.

    Furthermore, while we cannot understand how racism operates without understanding how it systematically sorts people into different socioeconomic positions, giving them different opportunities, race and racism cannot be reduced to class and class prejudice. The widened African American/European American disparity in birth outcomes among women of higher socioeconomic status/position illustrates this, as does the paradox of worse birth outcomes among US born Latinas and US born African Americans compared with their often economically worse off immigrant counterparts.

    An exclusive focus on class ignores or downplays the role of racism. The question is not which is more important, race or class, but how do we address both, including their complex interactions, with research and effective action.

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