Читать книгу A Companion to Medical Anthropology - Группа авторов - Страница 40

Biocultural anthropologists have increasingly focused on the health, nutritional, and other biomedical consequences of social and ecological vulnerability. Here we briefly discuss four “big tent” nodes, or meeting grounds, in critical biocultural research: (1) the biology and health of poverty and inequality; (2) social change, conflicts, and health; (3) biopsychosocial responses to stress; 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 rural areas. Such global-local processes are evident in both conquest and colonization, which had obvious health impacts through transmission of new diseases into previously unexposed populations, and the exploitation of environmental resources and labor.

A case in point is the decimation of native populations in the Americas. Using historic records and modern epidemiological health surveys, Santos and Coimbra (1998) evaluated historical changes in health of indigenous populations in Brazil through a series of historical events from initial contacts, to various economic booms and busts (rubber and timber), to more recent migrations of settlers into the Amazon. Settler colonialism is now frequently cited as creating the structural underpinnings for ongoing coloniality, persistent poverty, malnutrition, and health inequities among indigenous peoples worldwide. Santos and Coimbra’s ethno-epidemiological research, and most of the extensive literature examining the biology of populations forced into western ideologies and capitalist relations of production and consumption, point to the damaging health effects of these transitions often inadequately glossed as “modernization” or “market integration.” Yet, it is clear that transitions to market-based economies and other forms of capitalist relations can have negative, positive, and uneven effects on health (Dewey 1989; Kennedy 1994; Leatherman 1994; Pelto and Pelto 1983). This unevenness in the effects of markets on health and well-being provided a part of the rationale for the extensive multidisciplinary biocultural investigation in medical anthropology: the Tsimane’ Amazonian Panel Study (Leonard and Godoy 2008).

Tourism is an increasingly common form of economic development. Like other forms of capitalist development, tourism can have uneven impacts on the economics, culture, nutrition, and health of local groups (Ruiz et al. 2014). Research in the Yucatan of Mexico (Bogin et al. 2014; Leatherman and Goodman 2005; Leatherman et al. 2019; Pi-Sunyer and Thomas 1997), for example, has demonstrated the impacts of tourism on the social life, economy, identity, and diets of Mayan communities drawn into the tourist economy. One aspect of this research has focused on dietary change commensurate with the commoditization of food systems and increased consumption of processed foods and “junk” foods (Leatherman and Goodman 2005). Mexico is a leader in per-capita consumption of soft drinks, and poor children in Mayan communities may take in 20% of their calories through soft drinks and snack foods. Micronutrient deficiencies are evident in the diets of individuals with uneven access to secure jobs or sufficient land and labor to meet food needs through agricultural production. A pattern of undernourished and stunted children and overweight adults is emerging in these communities, which fits the pattern of emergent obesity and diabetes found in more urbanized areas of the Yucatan and elsewhere in the developing world.

One of the all too frequent and devastating social forces that populations respond to is armed conflict and the forced displacement of people. Conflicts lead to death and disability (the vast majority among non-combatants), displacement, environmental destruction, and exacerbate the full range of structural violence that is often the precursor to conflicts. While still rare among topics addressed in biocultural research despite the myriad conflicts over the past three decades, critical biocultural anthropologists have examined the biosocial consequences of conflicts on nutrition and health, growth, reproduction, and mental health (see the review by Clarkin 2019; Rylko-Bauer this volume). Kort et al. (2016), for example, has built a research program studying biocultural aspects of mental health in Nepal and Mongolia in the context of war. Clarkin (2019) has studied the effects of war and displacement on growth among the Hmong living in the United States and French Guiana. Leatherman and Thomas (2009) have discussed the social, economic, and health precursors to civil war in Peru and the impacts of conflict in an Andean setting.

Panter-Brick and colleagues’ (2008) work in Afghanistan illustrates the sort of findings emerging from many zones of endemic conflict. Stressors are often unevenly felt in unpredictable ways. In contexts of war, political insecurity, and household and family vulnerability, they found that mental distress, prevalence of psychiatric disorders and biomarkers of stress (blood pressure and Epstein–Barr virus) were most prevalent among women and girls (i.e., significant gender differences were evident), but mapped more closely onto familial contexts and cultural prescriptions in Afghan society than to economic distress or exposure to war-related stressful events.

Even rarer has been biocultural engagement with historical trauma, which has emerged as a construct to describe the impact of colonization, cultural suppression of historical oppression of Indigenous people in North America and elsewhere (Kirmayer et al. 2014; Prussing 2014). Work on historical trauma argues that the collective trauma experienced by one generation can be transmitted to subsequent generations impacting health and well-being (Brave Heart and DeBruyn 1998; Conching and Thayer 2019; Gone 2013; Jernigan 2018; Mohatt et al. 2014 ). Conching and Thayer (2019) have reviewed biological pathways, including epigenetics, through which historical trauma can affect health. Jernigan (2018) links historical trauma, loss of land, food and cultural sovereignty, and current rates of obesity. Smith (2020) has recently explored colonial masculinities that were central to colonization in the past and to ongoing coloniality through both historical records and current genetic profiles among American Indians in the United States. In summary, social changes tend to magnify existing inequalities and exacerbate the health of the most vulnerable. Critical biocultural anthropologists are addressing these issues by employing a wide range of methods in varied settings.

Biopsychosocial Responses to Stress Since the early 1980s, biocultural anthropologists have focused on psychosocial stress as a pathway to link lived experiences to biology (Goodman et al. 1988). The stress perspective can be traced to the pioneering work of Hans Selye (1956) on the activation of adrenal cortical and medullary stress hormone pathway. Stressors can include an excess or dearth of stimuli, and range from noise, to hunger, to traumatic events, to frustrations and concerns over a host of lived experiences. Also, perception of stress is critical to physiological response. As well, the physiological pathways between stressful stimuli and biological responses are linked to a wide variety of health conditions, and studying these pathways can contribute to broad preventative efforts. Thus, the stress perspective links culture, psychology, and political economy to a broad range of health conditions through specific physiological pathways and biological processes.

Biocultural anthropologists are now developing new methods for measuring stress responses in the field. Research has included a focus on stressful life events, social supports, and cultural consonance (Dressler and Bindon 2000), status inconsistency (McDade 2002), debt (Sweet et al. 2018), transitioning (Dubois et al. 2017), war-related trauma (Kort et al. 2016; Panter-Brick et al. 2008), and food (Hadley et al. 2008) and water (Brewis et al. 2020). Psychosocial stressors are then related to a series of biological outcomes such as child growth, blood pressure, cardiovascular disease, and more recently directly to stress hormones (e.g., salivary steroids) and immune function (e.g., EBV antibody level).

Measuring Stress in Humans, by Ice and James (2007), provides an excellent overview of a wide range of uses in measuring stress, via catecholamines, cortisol, blood pressure, and immune function measurements. The “anthropological trick” is to not only bring these methods to the field but to connect these specific mechanisms to the larger ideological and political systems in which we live. For example, in the next section, we note that racist acts (as stress events) are specific and content dependent but are also connected in meaning and structure to broader historical and social system.

Dressler and coworkers (2014) developed a set of concepts and techniques for measuring the degree to which individuals share cultural models (cultural consensus) and are able to act on these models in daily life (cultural consonance) that have been applied to a number of biocultural health studies (see also Gravlee et al. 2005; McDade 2002; Tallman 2018). Among other applications, the degree to which lack of cultural consonance is linked to stress and health can help illuminate the consistent findings that link status hierarchies and income inequalities to health (Marmot 2017; Wilkinson and Pickett 2011).

Stigma is a major source of stress and has been a frequent topic among medical anthropologists but less so among biocultural anthropologists. Brewis and Wutich (2014) have pointed out that along with the globalization of obesity, the stigmas around obesity have become global. Stigmas of obesity and other stigmas (Brewis and Wutich 2019) contribute directly to health by producing stress and limiting the range and effectiveness of responses to health problems. Their recent volume Lazy, Crazy, and Disgusting effectively employs a critical biocultural lens that considers evolutionary, political economic, cognitive, and biological dimensions of stigma as seen in obesity, mental illness, and in a range of public health initiatives. In their carefully balancing the potential health consequences of obesity and the stigma of overweight, Brewis and Wutich (2020) provide an example of the complexities and importance of ethnographically grounded biocultural research.

Embodiment of Race and the Health Consequences Racism It is now widely accepted that race is not in our genes but rather, race becomes biological through discourses and practices. Biocultural anthropologists, such as Michael Blakey (1998) have been at the forefront of questioning the naturalization of the idea of race. A key aspect of this work is a critical evaluation of how race is used in medical practice, specifically a systemic critique of the myth that health differences by race are due to racial differences in genetics (Goodman 2000). Rather, racism is seen as both a powerful psychosocial stress and a structural inequality, and the source for profound racial health disparities. Studies of the biology or embodiment of racism that call on both inequalities and stress as a source of racial health inequalities present another fertile area of research within a critical biocultural approach (Armelagos and Goodman 1998; Blakey 1994, 1998, 2001; Dressler et al. 2005; Goodman 1997; Gravlee 2009; Gravlee et al. 2005; Kuzawa and Sweet 2009).

Medical sociologists and social epidemiologists have led the way in the beginning to understand the magnitude and various manifestations of how racism is a public health issue leading to shorter lives and more illness and disease (e.g., Geronimus 1992; Krieger 2020; Williams and Mohammed 2013). For example, David and Collins (1997) have demonstrated how growing up in a racist society, rather than genetics, is related to low birth weight, and by extension, infant mortality. They show that the birth weights of babies born in African-born women are more like the birth weights of babies born to white women than black women who grew up in the United States.

Social epidemiologists have recently developed a number of interview guides and questionnaires that assess recent acts and perceptions of racism, racial discrimination and harassment, and implicit biases (for an excellent summary of this literature, see Karlsen and Nazoo 2008). In general, epidemiologists attempt to develop methods that are valid across context, in a universal way, but these instruments can miss the important sociocultural context of words, gestures, and actions. As well, most measures of racism focus on interpersonal issues and miss connections to the historic and structural features of the political economy of racism.

Recently, medical anthropologists working with critical biocultural perspectives have begun to address some of the inadequacies in these approaches by exploring how the lived experience of race and racism might lead to health differences. For example, Dressler and Bindon (2000) have linked the realities of being African American in the southern United States to cultural consonance, or the ability of individuals to approximate in their own behavior the shared cultural models of their society. Lack of consonance was associated with elevated blood pressure. In the end, they note that the inability to achieve the perceived goals associated with local cultural models might be anticipated for African Americans in racist societies where frequent unemployment, low wages, poor living conditions are part of the lived experience for many. Gravlee and coworkers (2005) begin with an ethnographic understanding of the meaning of skin color in Puerto Rico and demonstrate how those local meanings mediated experiences of racism and stress in specific local contexts; connecting social categories of race/color with socioeconomic status and blood pressure. These analyses offer a social, cultural, and environmentally based explanation for the racial variation in blood pressure found in much medical and public health research.

More recently, Gravlee and colleagues (2015, Rej et al. 2020) have developed a multiyear study using community-based participatory methods on the experience of discrimination and biological outcomes among African Americans living in Tallahassee, Florida (Gravlee et al. 2015). Their work follows from epidemiological studies on the experience of discrimination, with the addition that they considered both direct and indirect (friends and family network members) experience of bias (Rej et al. 2020). One aspect of this work has focused on how reported experiences of direct and indirect unfair treatment may be associated with telomere lengths (TL). Telomeres are found at the ends of chromosomes, and their shortening is an indicator of cellular health and aging. Prior research shows that TL is a risk factor for earlier onset of disease, and shortening of telomeres is associated with chronic psychosocial stress. Telomere length is but one of many mechanisms of how racism becomes biological, and collectively the known mechanisms and effects are probably just the tip of the iceberg. On a more theoretical and general level, this seems to be related to the weathering hypothesis originally proposed by Geronimus (1992) to explain the way that lifelong exposure to stress leads to low birth weight in African Americans. It may be that a good deal of the many unconscionable health inequalities by race is due to the weathering consequences of lifelong exposures to stress.

As we write, COVID-19 is exposing the depths of racial inequities in health among people of color in the United States. As of June 2020, the Centers for Disease Control and Prevention (CDC) reported that 21.8% of COVID-19 cases in the United States were African Americans and 33.8% were Latinx, despite the fact that these groups comprise only 13% and 18% of the US population, respectively. In a report of hospitalized patients, 33% were African Americans, despite representing only 18% of a catchment area population. The numbers have changed throughout time, but the disproportion has been consistent across the United States (Tai et al. 2020). Unsurprisingly, initially speculations as to race differentials in excess morbidity, hospitalization, and mortality focused on genetics, lifestyle, and preexisting conditions. However, it is now clear that genetics is not an explanation, and if anything, the genetic disadvantage is mostly pointed toward European-derived groups. “Life-style” is a risk but is related to the position of the poor and communities of color within larger political and social systems. They are more likely to be on the front lines, so-called essential workers, providing services during the pandemic and are thereby at increased exposure. Similarly, preexisting conditions such as obesity and heart disease are important risk factors, but these too are the result of racial inequalities in access to health care, nutrition, and also to the prior noted stresses of racism (Graves 2020).