The poor health of residents of the District's predominantly black Ward 8, where the death rate from cancer is 44 percent higher than in the city's white and wealthy precincts west of Rock Creek Park, could be more a function of class than of race.
The southeastern part of the city, where Ward 8 lies, includes some of the District's poorest neighborhoods. Residents there suffer from the same deprivations that afflict the poor wherever they live and whatever their color -- lack of access to health care, inadequate diets, stressful and unhealthy lifestyles.
In the United States, however, where blacks on average die six years younger than whites and where patterns of discrimination date back hundreds of years, the problems of areas like Ward 8 are more often than not explained in racial terms.
While Europeans analyze their health problems in terms of rich and poor and nations such as Britain carefully assign a class descriptor to every death certificate, the major organizations keeping health statistics in the United States do not consistently collect information on occupation, income and education. Until recently, for many health economists, given U.S. history and social organization, the piece of information most commonly cited to explain differences in patterns of death and disease among Americans has been the color of a person's skin.
A 'Deafening Silence'
But increasingly, some health experts have begun to question this orientation toward race. In a report highly critical of the U.S. health establishment published in the Nov. 17 issue of the British medical journal The Lancet, Johns Hopkins University sociologist Vicente Navarro charges that there is a "deafening silence" in the United States on the subject of how class differences and income inequities have affected public health.
"By looking only at race, we make it seem like race is the problem," Navarro said. "It is not. . . . Many of the things that are assumed to be characteristics of blacks are, in fact, characteristics of low income."
Unless they face this, Navarro says, it will be impossible for policy-makers to design health programs to meet the needs of the disadvantaged. He also said that by ignoring the influence of class, Americans may be guilty of "reverse racism, of making being black the problem."
Navarro's criticisms are controversial. Some say that he has given short shrift to the American racial legacy and has ignored important research on class differences in the United States. Nonetheless, he and a number of other sociologists and economists from both the left and the right have presented the health policy establishment with a series of provocative questions:
Is American health policy unduly preoccupied with race? Would Ward 8 residents have the same frequency of health problems if they continued to have the same income but were white?
Trying to tease out the reasons why one group develops a specific disease more often than another is, by all accounts, a difficult process. Because so many in Ward 8, for example, are both black and poor, it is difficult to determine which of those two factors is more important in accounting for the high cancer rates.
Comparing Groups on a Single Factor
To study such questions, epidemiologists try to hold all other conceivable variables constant and compare groups on the basis of a single factor. The black residents of Ward 8, for example, could be compared with a group of whites who have exactly the same occupations and income levels. Any differences could then be assumed to be the result of circumstances related to being black -- lingering discrimination, biological differences from whites, lifestyle factors that may contribute to health problems -- as opposed to disadvantages such as poor diet and reduced access to care that afflict the poor regardless of their color.
Using these kinds of studies, health experts such as Navarro have argued that income is actually far more important than race in predicting health.
Government medical data show, for example, that blue-collar workers (regardless of race) are 2.3 times more likely to die of heart disease than managers and professionals. In contrast, black males are only 1.2 times more likely to die of heart disease than white males.
Similarly, in a 1986 government study, people making $10,000 or less reported getting sick 4.6 times more often than those making more than $35,000 per year. Blacks reported getting sick 1.9 times more often than whites.
"People say to me, 'If we don't know the difference between black and white health, then we won't know what to do about it,' " said Milton Terris, editor of the Journal of Public Health Policy. "My answer is, why think of it in terms of white and black? Why not think of it in terms of rich and poor?"
But according to many health experts, the picture is more complicated. In the District, for example, blacks who live in Ward 3 have cancer death rates that are much closer to those of their white neighbors than to those of blacks in poorer parts of the city, suggesting a strong role for class in determining health.
But Ward 3 black male residents have death rates from prostate cancer that are twice those of white men living in Ward 3, suggesting that, for at least some diseases, income, class and access to good health care are not enough to equalize white and black health.
The same is true for infant mortality, where the national rate for blacks is about twice as high as that for whites. Studies have shown that the more educated a mother is, the less likely her infant is to die. But well-educated, upper-income black mothers still have slightly higher infant mortality rates than upper-income whites because they are more likely to have low-birthweight infants, which is the major predictor of infant death.
"There are biological factors that appear to have an independent effect," said David Mechanic, director of the health policy institute at Rutgers University.
Breast cancer data are even more complicated. Scientists know that the later women have children, the more likely they are to get breast cancer. This risk factor has the potential for producing a class-related difference, because lower-income women tend to have children earlier than their richer counterparts.
Jumble of Findings on Breast Cancer
But race also exerts an effect; there is evidence that black women have biological differences from whites that make breast cancer more likely to kill them. Combine the two effects, plus other factors, and scientists get a confusing jumble of findings: Below age 40, blacks have a higher incidence of breast cancer and above 40, whites do.
How much of a difference does being black make to health, above and beyond being poor? A recent Centers for Disease Control study analyzing close to 10,000 black and white adults found that only one-third of the substantially higher rate of premature death for blacks could be explained by income and occupational differences. Another third was apparently due to differences in risk factors such as high blood pressure, smoking and weight. But a full 31 percent of the difference could not be accounted for by anything except the race of the subject.
"If we assume that this is simply a class-related issue, we run the risk of not focusing on problems that may be related to the segregation and discrimination that still exist in our society," said University of Pennsylvania sociologist Linda Aiken. "Race has an impact over and above social class."