Race, Ethnicity, Class and Culture

 By Marcia Bayne Smith, DSW, Assistant Professor-Urban Studies Department

 Queens College-City University of New York 

Closing the Gap, The U.S. and U.K. Collaborate on Minority Health • March 1998 

S

everal studies have shown that the highest rates of poverty are 

concentrated among the same U.S. subgroups of non-White 

people who are also those with disproportionately worse health 

status. This health status of racial and ethnic minorities in the U.S. is 

a function of the very structure of the U.S. society. In this structure, 

racism and economic inequality are institutionalized. 

The result of this stratification is that greater deprivations accrue 

to those who are poor and non-White. This is true in every arena— 

material, emotional, psychological, and of every commodity: health, 

education, and political and economic power. 

The health care delivery system is no different than all other 

components of the U.S. social structure in terms of its reaction to race 

and class. In fact, health care in the U.S. is a multi-billion dollar 

industry that, in and of itself, is reflective of race and class divisions 

within society. 

In each component of the industry, there are very powerful interest groups, each with their own paid lobbyists, who are constantly at 

work to protect the industry’s dominance in the health care marketplace. 

Within this context, access to regular, ongoing primary health 

care in the U.S. is contingent upon the possession of health insurance, 

whether public or private, which is directly connected to one’s employment or lack thereof. This is a problem for significant numbers of 

minorities who tend to have higher rates of unemployment. Eligibility for Medicaid, the public insurance available to the poor, is based 

on stringent guidelines for means testing, which have now become 

even more rigorous as a result of welfare reform. 

The situation leaves large numbers without health insurance. 

Estimated to be anywhere from 40 to 75 million, the uninsured are 

actually two groups: the never insured and the sometimes insured. 

The latter group are the working poor whose low-income jobs customarily do not provide health benefits nor pay enough to purchase 

private insurance. 

U.S. health care delivery and policy targeting minorities has historically employed two opposing but similar approaches in terms of 

outcome. In one approach, the importance of race is downplayed or 

negated in health analysis. In the other approach, the claim is made 

that minorities experience poor health and premature death because 

of pathological behavior that includes a choice to smoke, drink heavily, 

consume the wrong foods, engage in unprotected sex and violent 

behavior, and lead sedentary lifestyles. 

This latter approach, known as “blaming the victim,” is reminiscent of earlier justifications used to defend health care policies that 

denied health care to Blacks during a time when racism was sanctioned by law throughout a majority of states in the Union. People 

thought that minorities were dying, so a commitment to care for them 

would be wasted. Unfortunately, variations of this argument continue to undergird minority health policy today. There are assumptions that individuals alone can control their health destiny without 

consideration of their economic capacity to do so, or the availability, 

cultural compatibility, or accessibility of health care services. 

It is important to note that this connection between health status, race and ethnicity, and socioeconomic status is not unique to the 

United States. This is a global condition that is well documented in 

the international health literature. The National Health Service (NHS) 

in the U.K. was designed largely to serve a homogeneous White population. So though the U.K. has a system of universal health access, 

minorities there—as is the case for minorities in the U.S.— do not 

always receive culturally and linguistically appropriate care. 

Both the U.S. and the U.K. are aware that any improvement in 

the health status of racial and ethnic minorities must flow from a 

strong research agenda. To deliver effective primary care services to the 

entire population of both countries, we must first acknowledge some 

critical factors. One is that given what we now know about the 

progressive nature of health deterioration over time and how this is 

influenced by behavior change, we must recognize that medicine has 

failed us in terms of its ability to help us change behavior. This is not 

to detract from the amazing life-saving technological advancements 

over the last 50 years. But the challenge of both countries is how to 

best bring about behavioral change, considering the extent to which 

health behavior and practices are influenced by culture. 

In many ways, the development of primary care as a national 

health services delivery strategy that meets the needs of everyone demands a new kind of research—one that is population driven. Research and needs assessments of minority communities must be conducted using totally new paradigms. The community must be involved in planning the research. Community members must be trained 

to serve as point persons in data collection, as they are much more 

likely to obtain data that is accurate than the outside researcher. And as 

data is analyzed, minority groups being studied must help interpret 

data. This type of research is beneficial because health education flows 

in two directions rather than one.

Office of Minority Health Resource Center U.S. Department of Health and Human Services