Book Review

Gender, Race, Class, and Health: Intersectional Approaches

N Engl J Med 2007; 356:317-318January 18, 2007

Article

Gender, Race, Class, and Health: Intersectional Approaches
Edited by Amy J. Schulz and Leith Mullings. 423 pp. San Francisco, Jossey-Bass, 2006. $60. ISBN: 978-0-7879-7663-7

Disparities in health resulting from social class, race or ethnic group, and sex have long been viewed as the elephant in the room of public health practice and discourse. But in fact, so often has the fundamental determining role of these social realities been exposed — even in high-profile clinical journals such as this one — that readers may feel a degree of ennui at further documentation of their magnitude and importance. This book is therefore welcome, as editors Amy J. Schulz and Leith Mullings strive to move beyond the description of these disparities to an understanding of their underlying determinants and a consideration of new approaches to alleviating them. Equally welcome is the disciplinary allegiance of the contributors; the strong representation of anthropologists distinguishes this book from the large number of collections on this topic that have been written primarily by epidemiologists and quantitative social scientists.

As indicated by the book's subtitle, many of the contributors draw explicit (and sometimes repetitious) attention to an “intersectional” theoretical framework that emphasizes how the intersections of sex, race or ethnic group, and class in specific contexts and populations influence health. Many of the contributors argue that understanding the determinants of the health of particular people in particular places at particular times requires forms of interpretation not offered by conventional epidemiologic or quantitative social science approaches. Ethnography and social history therefore join more conventional approaches in the exploration of the determinants of the wide-ranging disparities in health.

Mullings, for example, uses various methodologies in formulating the concept of the Sojourner syndrome (named after antislavery activist Sojourner Truth) to characterize the complexity of the resilience, resistance, and reaction that black women in New York City's Harlem have marshaled to shape reproductive health in their community. In a chapter tellingly entitled “Immigrant Workers: Do They Fear Workplace Injuries More Than They Fear Their Employers?” Marianne Brown reports on the Voices study of 75 immigrant workers in Los Angeles County and brings to light aspects of their working lives that have consequences for their health but are obscured in many epidemiologic studies of immigrant health. The chapters based on more quantitative frameworks benefit from the editors' unusually broad perspective, as in the engaging discussion of “health paradoxes” by Pamela Braboy Jackson and David Williams, with its focus on middle-class black men living at the intersection of the health effects of race, class, and sex.

The expansive vision of much of the work in this book draws attention to some peculiar absences. Most noticeable is the extreme U.S.-centric viewpoint. In a book that mentions “Euro- and androcentric bias” and that champions an intersectional approach that claims to move beyond conventional categories of explanation, it is odd to find virtually no discussion of the experience of people outside the United States. It could be argued that the focus of the book is the health of U.S. residents (and that the absence of reference to this focus in the title simply reflects a de facto acceptance of it among most readers). Still, comparative studies of different people in different places at different times can contribute to a better understanding of the situation in the United States.

The second omission relates to the position of class as “least among equals” of the intersecting forces central to this book. The first sentence of chapter 1 refers to “race/racism, class, and gender/sexism” as “matters of life and death.” For class, surprisingly, no experiential corollary is provided, as it is with race (racism) and sex (sexism). Indeed, the brilliant pioneering work of Richard Sennett and Jonathan Cobb in their 1972 book, The Hidden Injuries of Class (reprint edition; New York: W.W. Norton, 1993), has so rarely been developed in other studies that we may forget that the potential influences of class on health include the perceptions of inferiority, injustice, and powerlessness that can follow from economic dependency. It is particularly striking that there is so little discussion of this aspect of class in Gender, Race, Class, and Health, which privileges ethnographic descriptions of how inequalities are generated.

Biology completes the trilogy of aspects of inequalities given little recognition in this book. The ways in which experiences of inequality become literally embodied through prenatal experiences, infancy, childhood, and adulthood are hardly touched on. Instead, we get an understandable (but conventional) dismissal of genetic research that seems to consider genetics as the only relevant biologic science and one that tells us only about immutable and inherited processes. Neither claim, of course, is true.

The inevitable limitations of this book should not obscure its importance, however, as a coherent illustration of the potential contribution of qualitative social science to debates on disparities in health. The increasing engagement of multiple disciplines can only help us to understand and ultimately alleviate these avoidable inequalities.

George Davey Smith, M.D., D.Sc.
University of Bristol, Bristol BS8 2PR, United Kingdom