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CHAPTER 2 Critical Biocultural Approaches to Health and Illness

       Thomas L. Leatherman and Alan H. Goodman

      INTRODUCTION

      Human health is biocultural. Indeed, the recognition that human health, illness, and well-being are complexly interwoven biocultural processes, best understood through a variety of humanistic and scientific perspectives, is a foundational tenant of medical anthropology. Thus, it might be expected that biocultural approaches – ones that consider the many imbrications, linkages, and intersections between biology and culture – would be more represented in anthropological approaches to human health. However, while both the biological and cultural underpinnings of health are well recognized, integrative biocultural approaches in medical anthropology are less common, and critical biocultural approaches are relatively new.

      Critical biocultural anthropology, the focus of this chapter, falls within a bigger tent of biocultural approaches that encompass a broad range of contributions to medical anthropology, including foci on political economic, psychosocial, and evolutionary processes. Much of biocultural anthropology is an outgrowth of biological anthropology, and not all of these biocultural studies are critical in that they do not attend to social and political-economic processes and relations of power and inequality in their approach (i.e., the critical side of critical biocultural). This review specifically focuses on critical approaches in biocultural medical anthropology, perspectives that foreground power and inequalities, including the power and ideologies in biomedical research and clinical practices, and how inequalities shape conditions on the ground that lead directly to stress, pollution, nutrition, disease, and death.

These various approaches do not abandon ecological frameworks that long dominated biocultural anthropology, rather they attempt to integrate critical and political-economic perspectives with ecological frameworks. The goal of these efforts is not to reduce health and illness to biomedical terms and biological processes and mechanisms, but rather, to fully view human biology and health as inherently social and cultural. The question is not whether health is more biological or more cultural, but how human health processes are always both biological and cultural.

      Previous efforts to build such a synthetic bridge have taken several labels, including the “Biology of Poverty” (Thomas 1998), “Critical and Humanistic Biology” (Blakey 1998), “Political Ecology of Biology and Health” (Baer 1996; Leatherman 2005), “Critical Biosocial” (Singer 2011), and “Critical Biocultural Medical Anthropology” (Goodman and Leatherman 1998; Leatherman and Goodman 2011; Singer 1998 ). We use the term “critical biocultural” to locate this work at the intersection of critical medical anthropology and biocultural health studies.

      The goal of this chapter is to outline the history and debates leading to a critical biocultural anthropology and then to highlight contributions of a “critical biocultural” approach to medical anthropology. We first outline the emergence of critical biocultural approaches within anthropological studies of health and then discuss their place in medical anthropology and public health. We then review key areas of current research, and potential new directions for critical biocultural approaches. We highlight diverse contributions from biological and medical anthropologists that seek a deeper engagement with the social worlds of their interlocutors.

      The Emergence of Critical Biocultural Approaches

      Sobo (this volume) notes that medical anthropology has been dominated historically by two broad, contrasting perspectives: the symbolic/interpretive and the materialist, including a range of ecological and political economic perspectives. In the 1970s, as medical anthropology was growing as a defined subdiscipline of anthropology, bioculturally oriented medical anthropologists positioned themselves on the materialist side. Initially, they deployed ecological models that considered the interaction of host, pathogen, and environment (Armelagos et al. 1992). This ecological perspective was used to examine specific human–environment interactions where disease or other biological indicators of physiological perturbations (or stress) were evident. These causes of stress, the stressors, ranged from pathogens such as malaria to nutritional deficiency and psychosocial stressors. These early contributions clearly considered culture as part of the environment and took seriously how culture could buffer stressors or could be the source of stress.

      Human ecology also served as a framework for examining the evolution of disease and disease processes in contemporary human populations, often framed in terms of epidemiological transitions (Armelagos et al. 2005). In the ecological model, the host could be an individual or a group, the environment was composed of social and cultural as well as climatic and bio-geographic conditions, and pathogens were broadened from infectious agents to a wider category of insults such as physical violence, psychosocial stressors, protein-energy deficits, and anthropogenic toxins and pollutants.

The promise of an integrative ecological model in medical anthropology led many to conclude that a theoretically coherent integration of biological, ecological, and cultural domains had been achieved (for a longer analysis, see Goodman and Leatherman 1998). Yet, Landy (1983, p. 187) suggests that although medical ecological perspectives gained considerable acceptance, they only gained a “broad tacit consensus.” Like elsewhere in anthropology, ecological models were soon critiqued by critical medical anthropologists such as Singer (1989) for lack of attention to global and regional processes, social relations of power, overly functionalist and homeostatic orientations, and their reliance on the biomedical models of disease. Singer (1989, p. 223) sums up the critique from the critical medical perspective, stating “The flaws in medical ecology…arise ultimately from the failure to consider fully or accurately the role of social relations in the origin of health and illness.”

      At the same time that ecological models and the concept of adaptation were being challenged within cultural anthropology, critiques and reformulations were emerging from within evolutionary biology (Levins and Lewontin 1985) and also biological anthropology (Armelagos et al. 1992; Goodman et al. 1988; Leatherman 1996; Thomas 1998). These critiques were corrective responses to research in the 1960s and early 1970s, during which societies were seen as relatively closed and static, and human biologists were mainly focused on understanding genetic adaptations to stable physical and biotic extremes. However, two decades of research showed that human populations exhibited many more nongenetic (developmental, physiological and cultural, and now also epigenetic) responses than genetic responses to environmental stressors (Smith 1993). Thus, biological plasticity and sociocultural environments were recognized as the keys to understanding the human adaptive process (Hicks and Leonard 2014; Smith 1993).

      Importantly, too, political-economic and sociocultural processes were largely ignored in the search for genetic adaptations. Groups living in challenging physical environments are often also living in social environments with limited access to means of production, wage work, political power, health care, and education. The resulting stressors with origins in relations of power, such as food insecurity and malnutrition, invariably had a greater impact on biology and health than did physical stressors such as high altitude and cold temperatures (e.g., Greksa 1986).

      The “small but healthy” debate provides an example of the theoretical and applied significance of how bodies were read as adaptation or signs of stress. Developed by economist David Sekler (1981), the “small but healthy” hypothesis asserts that individuals who are short due to mild to moderate malnutrition (MMM) are nonetheless healthy and well-adapted, particularly to the circumstances of marginal food availability (Pelto and Pelto 1989, p. 11). Hence, economic and food resources need not be

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