A Companion to Medical Anthropology. Группа авторов
and, (4) the embodiment of race and the health consequences of racism. These nodes are neither the only ones we could choose nor are they independent from each other; rather, there are strong overlaps. Indeed, many health inequities are found at the intersection of poverty and inequalities, racism, and biopsychosocial stress. We present them as illustrative of studies that go beyond standard measures of socioeconomic status to study vulnerabilities along multiple axes that include race, gender, income, occupation, and access to health care.
The Biology and Health of Poverty and Inequality It is now well accepted that social inequalities underlay health disparities in a variety of contexts. It has also become clearer that inequalities are growing in contexts of globalization and present a major challenge to public health (Farmer 1999; Feachem 2000; Kim et al. 2000; Sen 1992; Wilkinson 1996; Janes and Korbett in this volume). Biocultural anthropologists have contributed to these observations over the past two decades through grounded research on the dialectical interactions among social inequalities, livelihoods, food security, nutrition, and illness [see for example, Volumes 35 (Mazzeo et al. 2011) and 38 (Leatherman and Jernigan 2014) of Annals of Anthropological Practice].
One longitudinal example of these interactions is found in the District of Nuñoa in the southern Peruvian Andes. Nuñoa has been a site for over fifty years of research and provides a particularly good case of how changing political and economic conditions map onto health. Work from the 1980s illustrated how profound poverty and political marginalization resulting from centuries of exploitation, a failed agrarian reform, and the penetration of capitalist markets, were linked to diminished diets, nutrition, health, coping capacity, food production, and household economies (Leatherman 1996, 2005). Poorer households with less secure access to land and few economic resources experienced worse nutrition and health, and experienced greater impacts of poor health on agro-pastoral production and household livelihoods, thus perpetuating and exacerbating poverty. These harsh realities throughout the central and southern Andes may have contributed to and surely were exacerbated by the civil war between Sendero Lumnoso and the Peruvian state (Leatherman and Thomas 2009 ).
More recently, Hoke and Leatherman (2019) demonstrated how post-conflict political economic conditions in the same area were associated with improved child growth and nutrition. Hoke (2020) has further demonstrated the continued importance of land sovereignty and home food production for child growth among families in Nuñoa across a wide range of ecological and economic contexts. Together, these studies provide ample evidence over time of how broad historical processes shape social, political, and economic vulnerabilities and opportunities that in turn shape dialectical interactions between lived realities and health.
At the start of the century, a report from the Worldwatch Institute (Gardner and Halweil 2000) estimated that over one billion of the world’s population was underfed, and FAO (2002) reported that 840 million people in the world were undernourished and six million children under the age of five died each year from hunger. Thus, an important focus in critical biocultural studies has been to explore links between economic vulnerability, food security, diets, and nutrition (see Himmelgreen et al. this volume). The role that the microbiome can play in nutrition (Benezra et al. 2012; Thompson 2012) and the role early nutritional stress can play in later health adds a further dimension to understanding links between food insecurity and health.
In an example from the global south, Panter-Brick and colleagues (2008) examined multiple aspects of household livelihood and intrafamilial malnutrition in Niger. They show how a host of structural and behavioral factors conspire to lead some children, but not others in the same family, to spiral down from mild to moderate to severe malnutrition. Families suffer from food insecurity, especially when fathers migrated in search of work. Foods they could afford were of poor nutritional quality, families spent relatively large sums on malaria treatments, and children were weaned early due to a high premium on fertility or perceived inadequacy of breast milk. Their work shows both the necessity to consider many dimensions of class and culture to understand intra-household nutrition and also that development efforts must do more than providing basic access to food.
Even more recently, critical biocultural anthropologists have extended research into insecurity to the issues of water insecurity (e.g., Brewis et al. 2020; Ennis-McMillan 2001; Wutich 2019 ; see also Whiteford and Padros 2011 and this volume) as an important biocultural problem of human health and well-being. Indeed, water insecurity may well be one of the greatest threats to human well-being in the coming century, especially given the climate change scenarios. Wutich (2019) notes that within the decade half the world’s populations are expected to be living in water-stressed conditions.
Estimates for “overnutrition” parallel undernutrition on a global scale (Gardner and Halweil 2000), and links between poverty, hunger, and nutrition are also strongly implicated in the global obesity pandemic (Himmelgreen et al. 2011, and this volume). Early in the emergence of overnutrition as an emerging public health crisis, Crooks (1998) investigated the relationships between poverty, diet, and obesity among poor families in Appalachia provide an example of the dynamics of these biocultural webs. Part of how poverty, diet, and nutrition in Appalachia are linked is the consumption at home and in schools of calorie-rich but nutrient-poor foods. Home environments are linked to structures of parental work, perceptions about providing for the wants of their children, and child-activity patterns. School environments offer the ready availability of calorie-rich and nutrient-poor snack foods because snack food concessions were one of the only sources of income for school-based extracurricular activities in these impoverished counties. Thus, structures of poverty severely limit options for meeting personal, social, parental, and dietary goals and needs, and the result is the global association between poverty and obesity. Moreover, as Brewis and Wutich (2014, 2019) have shown, stigmas associated with weight, as with poverty in the work of Crooks, serve to undermine anti-obesity programs and further contribute to a syndemic of poverty, obesity, diabetes, and multiple associated health outcomes (see also Ginzburg 2020).
Finally, the research on health syndemics (Mendenhall 2012; Singer 2011) has become an important locus for collaboration among biological and bio-culturally oriented medical anthropologists, and an area where deeper biocultural/biosocial integration has emerged. Singer and Clair (2003) introduced the notion of “syndemics” as the synergistic interactions of two or more diseases often clustering within populations suffering from multiple axes of inequalities in biosocial contexts. Syndemics has been adopted as a framing concept to address clusters of disease and social problems such as substance abuse, violence, and HIV/AIDS that cluster in inner-city, impoverished women (SAVA Syndemic–Singer 2009) and depression, diabetes, and social distress among Latina immigrants in Chicago (VIDDA Syndemic–Mendenhall 2012). Syndemics research is grounded in an integrated biosocial approach that links structural forces to structural vulnerabilities to disease, and explores biological and social pathways of embodiment (Bulled et al. 2014; Singer and Bulled 2012/2013; Singer et al. 2017). This then requires a mixed-method approach integrating quantitative with qualitative data, and ethnographic as well as more structured and biomedical analyses. And it has obvious applied implications for how we create policy and provide care to those living with greatest inequalities and at greatest risk to illness and disease (Mendenhall et al. 2017).
Social Change, Conflicts, and Health A deeper appreciation of history and global political-economic processes makes clear that humans are invariably in transition – be it a food production shift from foraging to food production, from colonization, or from insertion into global capitalism. Armelagos and colleagues (2005) framed the major shifts in political economies and ecologies across human history in terms of epidemiological transitions in disease patterns resulting from evolutionary, historical, and political-economic processes associated with social change. Biocultural anthropologists interested in the health consequences of these transitions have addressed shifts from foraging to food production (Armelagos and Cohen 1984; Goodman 1998), the demographic devastation and subsequent long-term health consequences of conquest and colonization (Santos and Coimbra 1998), and the more recent transitions into market economies (Leatherman 1996: Leonard and Godoy 2008).
In assessing the first transition from foraging to farmer, Goodman (1998) argues that political hierarchies and resource extraction from the peripheries to the center of precapitalist social formations played a key role in declining health in