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forms of malnutrition. In response, Raynaldo Martorell (1989) argued that while smaller people require fewer calories, their “smallness” entailed substantial social, behavioral, and biological costs. The same caloric deficit that causes slowed growth also decreases resistance to disease and ability to work and reproduce. As Pelto and Pelto (1989, p. 14) conclude, “…the concept of a ‘no-cost’ adaptation makes virtually no sense.” The “small but healthy” debate was key to a reexamination of the adaptation concept, and alerted many to the political implications of their science, in this specific case, whether or not millions of MMM Indian children would receive food aid.

Biocultural research in the 1990s increasingly became oriented toward documenting biological compromise or dysfunction in impoverished environments (as opposed to adaptations) and the biological impacts of social and economic change (Thomas 1998). Social environments took precedence over physical environments, and measures of stressors expanded to include psychosocial stressors and their impact on health conditions such as hypertension and immune suppression (e.g., Blakey 1994; Dressler and Bindon 2000; Goodman et al. 1988; McDade 2002). Yet, while it became relatively common to associate biological variation with some aspect of socioeconomic variation, the context and roots of the socioeconomic variation were infrequently addressed. For example, research on “modernizing” populations documented how devastating such changes can be on human biology and health but provided little or no information about processes of modernization (Bindon 1997). The socioeconomic conditions, workloads, and environmental exposures that contribute to diminished health were conceptualized as natural and even inevitable aspects of changing environments, rather than contingent on history and social and economic relations.

      Critiques of the ecological model from critical medical anthropologists such as Singer (1989) led to spirited debate on the pages of Medical Anthropology Quarterly, including a defense of the ecological approach and biocultural paradigm in medical anthropology by Andrea Wiley (1992), a subsequent series of rejoinders and commentaries (e.g., Leatherman et al. 1993), and a collection of papers and commentaries on “Critical and Biocultural Approaches in Medical Anthropology” in 1996 (Baer 1996). These dialogues were formative in developing a critical biocultural anthropology that emerged from efforts to “build a new biocultural synthesis,” which was the focus of a Wenner-Gren symposium in 1992 (see Goodman and Leatherman 1998). The conference brought together cultural and biological anthropologists, many of whose work focused on human health, to consider how we might better formulate critical and political-economic biocultural approaches. A number of themes, presented later, emerged from discussions at the conference, the subsequent volume and further efforts to advance a critical biocultural approach to health and illness.

      Themes in a Critical Biocultural Perspective

      In this section we overview core themes in critical biocultural medical anthropology. Research projects and practitioners vary in the ways they emphasize (or do not) these themes in their work, and there are no hard rules or litmus test about whether a project is “critical.” We present these to provide a guide to common and core themes (see also, Goodman and Leatherman 1998; Leatherman and Goodman 2011).

      Expanding Geographic and Historical Scopes The first fundamental theme of critical-biocultural approach is to expand the geographic and historical scope of analysis to examine how nations, communities, populations, and even viral pathways (Garrett 1994) are inextricably interconnected at regional, national, and global levels. Local environments and biologies are often the focus of research but themselves emerge from broader and deeper global histories.

      Borrowing from Farmer’s (2004) outline for an anthropology of structural violence, these approaches aim to be “geographically broad” and “historically deep.” For example, the poor health of Haitian workers on Bateys associated with sugarcane estates in the Dominican Republic is clearly linked to conditions of abject poverty, limited occupational opportunities, unhygienic environments, and limited access to health care (Simmons 2002). These conditions are not just unfortunate realities but products of a history of colonialism in the eighteenth-century Caribbean, conflicts between Haiti and the Dominican Republic during the nineteenth century, and more recent human rights and migration policies that deny equal rights and access to resources to Haitian workers (Farmer 2004; Martinez 1995; Mintz 1985; Simmons 2002). In Europe and the People Without History, Eric Wolf (1982) opened up the view of closed eco-cultural systems and recontextualized “people without history” within historical and larger political economic processes. A critical biocultural medical anthropology aims to extend this recontextualization to processes under the skin, bodies, and human biologies.

      Relations of Power and Structural Inequalities A second theme is a focus not just on wealth and poverty as economic correlates to health disparities but also on the power relations that structure resource inequalities. Absolute and relative wealth, income, and resource differentials, and the perception of inequalities are all clearly related to poor health (Lynch 2020; Marmot 2017; Wilkinson and Pickett 2011). These all emerge from more deep-seated social, economic, and political structures that limit access to basic resources, deny equal human and political rights, and constrain agency; in short, that limit ones’ life chances. These resource and class-based inequities intersect with other forms of inequality such as racism and sexism, calling for an intersectional approach to power and inequality (Hill Collins 1990; Schultz and Mullings, eds. 2006).

      For example, despite being residents of the wealthiest nation in the world, African-American males have life expectancies on par with individuals living in parts of rural India and China (Sen 1992), and African-American babies and mothers women are two and three times more likely to die in childbirth. The recent global pandemic of COVID-19 has hit the poorest segments of many nations the hardest. In the United States, Native Americans, African Americans, and Latinx groups are 2.8 times more likely to contract the virus, and African Americans are twice as likely to die from COVID-19 as white counterparts (CDC 2020; Graves 2020). These health inequities, and many others, are not accidents of occurrence or merely results of proximal measures of resource access but are reflective of deeper purposeful patterns of intersecting histories; what Farmer (2004) has called the “social machinery of oppression” and Hill Collins (1990) the “matrix of domination.”

      Critical Reflections on Knowledge Production In addition to structuring lived experiences, power relations structure the production of knowledge (Foucault et al. 2008; Morgan 1998). The third theme is a focus on critical reflections on science, including the questions we ask, the methods and analyses we employ, the results we reach, how research is funded, and how it impacts our lives. If the social contexts of science and research are left unquestioned, then our subjectivities and assumptions are left unexamined. Often this has led to interpretations of inequality as inevitable and natural. A critical biocultural approach recognizes the inherent political dimensions of all research, whether explicit or implicit (e.g., political ramifications of the “small but healthy hypothesis”). Taking a critical perspective on scientific knowledge production, rather than being anti-scientific, as it is often portrayed, is a step toward a more reflective science.

Human Agency A fourth theme is a greater attention to human agency in constructing environments and actively and creatively coping with problems and uncertainties. The goal here is a focus on the interplay between “structure and agency,” how social relations are constructed through human actions and simultaneously serve to structure those actions. Parallel arguments within evolutionary approaches highlight the role of organisms in constructing the very niches assumed to be the context of adaptive response. To say that one’s actions contribute to the social and environmental contexts of everyday lives in no way seeks to focus blame on lifestyle choices as the cause of their health problems. Rather, the idea is to understand how inequalities constrain agency and thus create contexts where the costs inherent in social and behavioral responses to stress are likely to be amplified. Human actions create spaces of vulnerability for some more than others, and individuals experience, perceive, and respond to conditions of vulnerability in different ways, shaped by their social and cultural position. It is always appropriate to ask “adaptive for whom” and in “what context”; who gains and who loses. As critical epidemiologist Nancy Krieger (2001, p. 674) comments, it is important

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