“This book provides a clear, accessible entry into one of the author’s main contributions to public health literature—the ecosocial theory of disease distribution—with helpful examples for the application and importance of this theory for a general audience. Many communities of color will resonate with her explanation of the interdependence of societal and environmental situations on unequal and disparate health outcomes.”
—RANDALL AKEE,
Department of Public Policy and American Indian Studies, University of California, Los Angeles
“A tour de force, Nancy Krieger’s latest book weaves together decades of her own pioneering work integrating ecosocial theory, empirical research, and transformative policy and politics. This clear-headed cri de coeur is guided by Krieger’s dazzling intellect, deep historical and contextual understanding, methodological knowhow, and above all is motivated by her lifetime of commitment to social and health justice.”
—ANNE-EMANUELLE BIRN,
Global Development
Studies,
University of Toronto
“Nancy Krieger’s groundbreaking concept of ecosocial theory has influenced a generation of environmental and public health scholars. Her expanded framework on discovering truths explores how diverse points of pollution, social stratification, and poverty intersect through the human body. This is a must-read for anyone seeking to advance environmental and racial justice in the public health field.”
—MICHAEL MÉNDEZ,
Department of Urban Planning and Public Policy, University of California, Irvine, and author of Climate Change from the Streets: How Conflict and Collaboration Strengthen the Environmental Justice Movement
“In this landmark book, Nancy Krieger makes a compelling case for not simply working to address health inequities but grounding that work firmly in ecosocial theory and a deep understanding of the ‘embodied truths our bodies tell.’ A masterpiece, from one of the most important public health scholars of the last half century.”
—MEREDITH MINKLER, School
of Public Health, University of California, Berkeley, and co-editor, Community Organizing and Community Building for Health and Social Equity
“This book connects all the dots—structural racism, class, power, gender, white supremacist culture, policy, ableism, and more— providing the most elegant and accessible explanation of how they all interact, connect, and shape not only embodied health but our
environment and public policy. The stories, the data, and the analysis are deftly on point. This book is an absolute game changer.”
—MAKANI THEMBA, Higher Ground Change Strategies
“Nancy Krieger’s conceptual thinking has been pushing the boundaries of epidemiological theory for decades now. This ‘small book’ will rapidly become essential reading for all those who use epidemiology to tackle the multiple dimensions of inequality affecting our societies.”
—CESAR VICTORA,
International Center for Equity in Health, Universidade Federal de Pelotas, Brazil
“Building on decades of research, Nancy Krieger’s eloquent writing takes us on a journey through history, science, and sociology to peel back surface explanations and reveal what truly shapes our health. This exposé of how our bodies reflect the embodied truths of society should be required reading for anyone seeking to understand health disparities.”
—STEVEN WOOLF, Center on Society and Health, Virginia Commonwealth University
Small Books, Big Ideas in Population Health
Nancy
Krieger, Series Editor
1. J. Beckfield. Political Sociology and the People’s Health
2. S. Friel. Climate Change and the People’s Health
3. J. Breilh. Critical Epidemiology and the People’s Health
4. N. Krieger. Ecosocial Theory, Embodied Truths, and the People’s Health
ECOSOCIAL THEORY, EMBODIED TRUTHS, AND THE PEOPLE’S HEALTH
Nancy Krieger PROFESSOR OF SOCIAL EPIDEMIOLOGY AND AMERICAN CANCER SOCIETY
CLINICAL RESEARCH PROFESSOR
AT THE HARVARD T.H. CHAN SCHOOL OF PUBLIC HEALTH
Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries.
Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America.
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Library of Congress Cataloging-in-Publication Data
Names: Krieger, Nancy, author.
Title: Ecosocial theory, embodied truths, and the people’s health / by Nancy Krieger. Other titles: Small books with big ideas ; 4.
Description: New York, NY : Oxford University Press, [2021] | Series: Small books, big ideas in population health ; 4 | Includes bibliographical references and index.
Identifiers: LCCN 2021024150 (print) | LCCN 2021024151 (ebook) | ISBN 9780197510728 (hardback) | ISBN 9780197510742 (epub) | ISBN 9780197510759 (ebook)
Subjects: MESH: Health Status Disparities | Socioeconomic Factors | Social Justice | Health Equity | Social Medicine | Epidemiologic Methods
LC record available at https://lccn.loc.gov/2021024150
LC ebook record available at https://lccn.loc.gov/2021024151
DOI: 10.1093/oso/9780197510728.001.0001
This material is not intended to be, and should not be considered, a substitute for medical or other professional advice. Treatment for the conditions described in this material is highly dependent on the individual circumstances. And, while this material is designed to offer accurate information with respect to the subject matter covered and to be current as of the time it was written, research and knowledge about medical and health issues is constantly evolving and dose schedules for medications are being revised continually, with new side effects recognized and accounted for regularly. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulation. The publisher and the authors make no representations or warranties to readers, express or implied, as to the accuracy or completeness of this material. Without limiting the foregoing, the publisher and the authors make no representations or warranties as to the accuracy or efficacy of the drug dosages mentioned in the material. The authors and the publisher do not accept, and expressly disclaim, any responsibility for any liability, loss, or risk that may be claimed or incurred as a consequence of the use and/or application of any of the contents of this material.
I dedicate this book to my parents, Dr. Dorothy T. Krieger (1927–1985) and Dr. Howard P. Krieger (1918–1992), who taught me to value knowledge for the good we can do with it in the world, and to Mrs. Montez Davis (1913–1997), who helped raise me and further opened my eyes to injustice and to living a loving life.
EPIGRAPHS
. . . the crucial distinction for me is not the difference between fact and fiction, but the distinction between fact and truth. Because facts can exist without human intelligence, but truth cannot.
Toni Morrison (2019) 1
. . . true stories are worth telling, and worth getting right, and we have to behave honestly towards them and to the process of doing science in the first place. It’s only through honesty and courage that science can work at all. . . . The more we discover, the more wondrous the universe seems to be, and if we are here to observe it and wonder at it, then we are very much part of what it is. . . . The story continues, and the rest is up to us.
Philip Pullman (2017) 2
Discourse is not just ideas and language. Discourse is bodily. It’s not embodied, as if it were stuck in a body. It’s bodily and it’s bodying, it’s worlding. This is the opposite of post-truth. This is about getting a grip on how strong knowledge claims are not just possible but necessary worth living and dying for.
DONNA
HARAWAY (2019) 3
CONTENTS
Preface xi
Acknowledgments xvii
1. From Embodying Injustice to Embodying Equity: Embodied Truths and the Ecosocial Theory of Disease Distribution 1
2. Embodying (In)justice and Embodied Truths: Using Ecosocial Theory to Analyze Population Health Data 55
3. Challenges: Embodied Truths, Vision, and Advancing Health Justice 129
Notes 177
Index 327
PREFACE
Health, illness, birth, and death: they comprise the embodied truths of existence on our planet Earth for every single biological being. It is an elementary truth that to live is to live embodied. People and all other living beings are constantly engaging with— and depending upon and shaping—the social, biophysical, and ecological contexts in which life transpires. This translates to literally incorporating, bringing into the corps, the body—that is, embodying biologically—the dynamic contexts in which our lives are enmeshed. Patterns of population health—including, in the case of people, health inequities—constitute the living record of how each population and our planet are faring.
Yet elementary truths are never as simple as they appear to be. This book aims to provide a systematic rendering of the ideas and causal claims entwined with the notion of embodying (in)justice and its implications for public health and social justice in its many interlinked forms—including but not limited to racial justice, economic justice, reproductive justice, environmental justice, climate justice, Indigenous justice, queer justice, disability justice, and more. The basis of this construct is the ecosocial theory of disease distribution, which I explain in Chapter 1, and which I first articulated in 1994 and have been elaborating since.1 Theories and their causal constructs matter because they can be a source of power,
for good and for ill, especially when deployed and contested in systems of governance, economics, and politics that set the terms by which people and this planet can either thrive or be treated as entities to be exploited for the private gains of a few. Using concrete examples to illustrate critical concepts, the goal of this book is to use the ecosocial theory of disease distribution to promote clear thinking about the distinct but connected realities of embodying (in)justice and embodied truths. The intent is to inform critical and practical research, actions, and alliances to advance health equity in a deeply troubled world on a threatened planet.
Throughout, the focus on embodying (in)justice and health equity is central—albeit with no claims that health is the sole or most important consideration, since there are so many facets and features of social justice that warrant deep analysis and concerned and concerted action. To me, however, concerns about health are compelling, complex, and multifaceted. So too is the critical work of critical science, done by real people in real societies, in ways that can contribute publicly testable and tested ideas and evidence. I offer this brief book to share insights I have gained through my 35+ years of professional work as a social epidemiologist and as an advocate and activist linking issues of social justice and public health. The intent is to provide an invitation and opportunity to reflect on ideas that can lead to deeper, more rigorous, and actionable analysis, not a comprehensive review of the literature.
This book is one of several volumes for a series I initiated with Oxford University Press, on Small Books, Big Ideas in Population Health. 2 I conceived of this series because in my view the practice and science of the intermingled fields of public health and population health sciences could benefit from strengthening the critical
conceptual tools of our trade—that is, the ideas we use to guide our research and practice in the real world. Reaching out beyond my own particular expertise, I wanted to bring a sharp focus to a diversity of key debates and insights in public health and kindred disciplines that could help hone these tools for thinking—and I recognized that this required a format longer than the standard brief scientific article and shorter than a full-fledged tome. Hence small books with big ideas!
The first two books in this series engage with big ideas under the rubrics of (1) Political Sociology and the People’s Health, by Jason Beckfield, published in 2018,3 and (2) Climate Change and the People’s Health, by Sharon Friel, published in 2019.4 The former cogently explicates how to understand, research, and reveal the “rules of the game” that structure population health and health inequities; the latter incisively offers one of the first in-depth analyses of links between the climate crisis and health inequities, their common roots in consumptogenic systems, and possibilities for progressive policy systems change. The third book, published in January 2021, is by Jaime Breilh; titled Critical Epidemiology & the People’s Health, 5 it deftly presents critical Latin American perspectives that play an influential role in the epidemiology and public health (and collective health) of the Global South but that are less familiar in the Global North. Two other books in preparation are on epigenetics and the people’s health, and on causal inference and the people’s health, and others are in discussion, including on Indigenous well-being, settler-colonialism, and the people’s health, with more to come. I am grateful to my colleagues who have stepped forward to be included in this series.
My own writing of this book comes at a time of heightened awareness of the urgent need for critical analyses of the structural drivers of population health and health inequities—and the power of people to change conditions for the better, including for the people’s health. I began working on the text in mid-January 2020, when only whispers of a possible new infectious disease with pandemic potential began circulating into global awareness. I continued writing until mid-March and then had to halt, when the demands of dealing with COVID-19 and health inequities in the United States, on top of all the other COVID-19 disruptions to work and life, became my priority. Added to this was the horrific public murder of George Floyd on May 25, 2020, by the Minneapolis police, one that, building on far too many before, sparked subsequent weeks and months of mass protest throughout the United States and globally—against not only police violence but also structural racism more broadly.6 Addressing racial injustice and health, including in relation to other forms of social injustice, has been central to my work as a social epidemiologist since the start of my professional career—and indeed part of why I entered this field.
In March 2020, I thus put aside work on this book, given the urgent need to put my epidemiologic skills swiftly to use to the critical work at hand, regarding the data, debate, and action around COVID-19, police violence, and structural racism more generally.7 I was able to revisit the writing in brief moments during the summer of 2020, then put it aside again for much of the fall, given the demands of school, the pandemic, and the presidential and other elections.8 Nevertheless, in late December, as contest over the elections began to recede and vaccines started to become
available, even as COVID-19 in the United States continued to spin out of control, I could return to my writing. I completed a first draft just days before the anti-democratic violent assault on the US Capitol on January 6, 2020, and in February, with comments from colleagues in hand, revised while the impeachment trial was underway.9 This is writing in the real world, in context.
Living through 2020 and the myriad efforts to mobilize for health justice served only to strengthen my resolve to prepare this book. My intent is to provide clarity about the nature of the embodied truths revealed by population patterns of health—so as to hold accountable the systems, institutions, and individuals that promote the degradation and plunder of people and this planet for the benefit of a few. During the past decade, there has been a global rise in reactionary attacks on the ideas, policies, scientific evidence, and movements needed for people and life on this planet to thrive equitably.10 The urgency of repelling and exposing these repellent attacks is more important than ever.
Yet when it comes to the people’s health, we need not only critical political and economic analysis but also a deep engagement with biology, in societal, ecological, and historical context. Such knowledge is necessary on its own terms, for effective action, and also to counter dominant narratives that continue to attribute primary causal agency to people’s allegedly innate biology (aka genomes) and their allegedly individual (and decontextualized) health behaviors.
Hence this book: to illuminate critical ecosocial theorizing about embodying (in)justice and embodied truths, so as to strengthen work for the people’s health. To its pages, I bring my own sense of living in history, both to explicate how I have developed my ideas and
why, and, beyond this, to look forward: to who and what come next. May the arguments presented in this book better equip you, the reader, to take on the work of your generation in context— whatever it is, and whenever and wherever you may be. The collective challenge is for we who value health equity and human rights to contribute our part to the global project of ensuring the terms whereby all can thrive, alive to the sensuous possibilities of living engaged, generative, and loving lives on this planet, for generations to come.
ACKNOWLEDGMENTS
I would like first to thank my editors at Oxford University Press who have worked closely with me on this book series: first Chad Zimmerman, and presently Sarah Humphreville. I would also like to thank Lisa Dorothy Moore, George Davey Smith, and Jason Beckfield, as well as Sarah Humphreville, for taking the time to read an early draft and offer their helpful comments (and suggested references!). I am grateful to staff throughout the Harvard library system, who have responded to my many requests for books and articles over the years—and then, as COVID closed the libraries, continued to assist by scanning materials I sought. I would also like to thank Pam Waterman and Jarvis Chen for their many years of creative collaboration, helping translate my ways of using ecosocial theory into real-world research. Support for my work on this project derives from my 2019 sabbatical funding (Harvard T.H. Chan School of Public Health, to develop the book prospectus) and from my American Cancer Society Clinical Research Professor Award (2015–2020) and its renewal (2020–2025).
I also offer my thanks for support in the many ways it showed up from my brother Jim Krieger and from the many others in my family of choice (you know who you are!). I close with thanks to Emma (1981–1996), Samudra (1996–2014) and Bhu (1996–2010), and Amber (b. 2014) and Sky (b. 2014), for reasons only cats can know.
FROM EMBODYING INJUSTICE TO EMBODYING EQUITY
EMBODIED TRUTHS AND THE ECOSOCIAL THEORY OF DISEASE
DISTRIBUTION
Is it a mystery that people subjected to economic deprivation, discrimination, and hazardous working and living conditions, compounded by histories of enslavement and colonization, typically have worse health, have worse health care, and die younger than people with economic, social, and legal privileges?1 It shouldn’t be. Observations about associations between societal power, position, and health status, that is, the societal patterning of population health, appear in the earliest known medical writings, dating back several millennia—for example, in texts from the ancient Egyptian, Greek, Indian, and Chinese civilizations, to name a few.2 Systematic documentation of such associations was also central to many of the founding reports, in the mid-19th century CE, of the field of public health in Europe and the Americas.3 However, it is one thing to observe an association. It is another to explain it. This is why theory, causal assumptions, and frameworks are key, not just the observable “facts.”
The crux of the argument, as conventionally posed, is who bears responsibility for the observed social patterning of population health: individuals or their societal context, past and present?4
The stakes in this debate are high since they concern accountability—and these debates repeatedly founder on the ubiquitous individual/population divide that permeates both individualistic and social analyses of health. The standard poles of the argument are as follows:
• If the fault for poor health, or the privilege and praise for good health, lies within individuals, their innate biology, and the social groups with whom they individually and independently choose to affiliate, then, per the dominant status quo framing, social group differences in health are simply a reflection of innate biology, values, and choices.5 Health, from this standpoint, is an individual resource.
• If, however, responsibility lies within societal systems in which some groups have power at another group’s expense, in ways that affect options for living a healthy life, then the social group differences in health constitute health inequities, that is, differences in health status that are unfair, avoidable, and in principle preventable.6 Health, from this standpoint, is socially contingent, and improving health equity becomes a collective resource.
The rub is that the computation of population rates—be they of birth, health, illness, or death—requires counting individuals in both in the numerator (i.e., the “cases”) and denominator (i.e., the population in which the “cases” emerge). Does this mean that population health simply reflects aggregated individual health status? No. But it takes a new way of theorizing health—as emergent embodied phenotypes to understand, explain, and act to change the embodied truths of population health. This book enters these debates with three premises:
• First, the familiar framing of individual versus society is dangerously wrong, especially in relation to health. On our planet Earth, no individual (of any species) ever lives—or ails or dies—separate from this world. Rather, we inhabit a planet in which every living being necessarily (1) is simultaneously an individual and part of a population shaped by its history, and (2) engages dynamically with members of their own and other species in their broader ecological context.7
• Second, every living being’s body tells stories of its experiences8 what I here newly term embodied truths which both reflect and shape its engagement with other organisms and the rest of the biophysical world. Stated another way, all organisms live their phenotype(s), not genotype—and this phenotype is not fixed.9 What we live is our emergent embodied phenotype, 10 one that emerges through engagement with the dynamic social and biophysical features of the dynamic changing world we inhabit and alter. A corollary is that the embodied truths of individuals’ lives are inseparable from the embodied
truths revealed by analysis of distribution and causes of population rates of health, disease, and well-being.
• Third, the reason to analyze health inequities is not to prove that injustice is wrong, since injustice is wrong by definition.11 Rather, the point is to illuminate how both injustice and equity can respectively shape people’s health and the health of our planet for bad and for good, so as to guide action and allocation of resources for prevention, redress, accountability, and change.12
In this first chapter, I accordingly introduce key concepts and arguments concerning embodiment and people’s health, as grounded in the ecosocial theory of disease distribution.13 In Chapter 2, I provide a range of supporting empirical examples. In Chapter 3, I step back and consider the critical challenges and contributions the ecosocial constructs of embodiment, embodying (in)justice, emergent embodied phenotypes, and embodied truths can offer for sparking new questions and producing new scientific knowledge that can help advance health justice in its myriad forms.
Debating “Individual” Versus “Social” Causes of Health and “Gene-Environment Interaction”: “Déjà Vu All Over Again”14
One can be forgiven a deep sense of fatigue when jumping into current controversies over causes and patterns of population health. However, some background and context is necessary. Given the stakes, it should be no surprise that current debates still follow contours of contention—individual versus societal responsibility for population health—traced out over two centuries ago in the founding documents of the field of public health.15 They likewise echo the worldwide arguments over eugenics in the 1920s–1940s
spurred both by US Jim Crow and anti-immigration politics and, related, by Nazi and other fascist regimes.16 They are once again rehearsed in contemporary clashes over whether racial/ethnic health divides reflect “cultures of poverty” and “Black pathology” versus structural racism.17
Nor are these debates unique to public health. Again, not surprisingly, given the stakes, parallel arguments pitting individuals versus society— as causal agents, as units of analysis—are littered across kindred fields, including sociology, anthropology, economics, medicine, medical and health geography, psychology, philosophy, and science and technology studies, to name a few.18 The ubiquity and persistence of these debates, endlessly updated with the latest evidence afforded by whatever the newest technology permits, attests to relationships between the causal frameworks public health scientists and other scholars use— and contest— and the political and societal systems and issues at stake.19
In the case of public health, what specifically is at issue is whether, as noted earlier, social group differences in health status are (1) “natural” and fair, versus (2) societal in origin and unfair. Framed in terms of “bodies,” the core causal question is whether causal agency and explanations for population health patterns
1. reside in individuals, by virtue of their innate biology—aka the “body natural”—and their individually chosen or possibly genetically determined behaviors, values, and social group or cultural affiliations,20 versus 2. reside in the “body politic”—aka the priorities, policies, and practices of the political and economic systems governing the conditions in which individuals live.21
In the first case, population patterns of health simply arise from the aggregation of individuals, and the corresponding interventions, whether biomedical or behavioral, are focused on individuals. In the second case, population patterns of health reflect societally structured ways of living, thus requiring interventions focused on equitable societal changes to enable healthier living. While both accounts can (and should) recognize that inherently stochastic random events can affect both individual risk and population rates of disease, they differ in whether they frame these chance occurrences (for good or for bad) as being a matter of private individual luck versus socially structured chance.22
Of course, the posing of an “either/or” argument is stark—and can be viewed as a simplistic polemic.23 The past half- century’s conventional “solution” has been to proffer “gene × environment interaction” (GEI) as an alternative.24 But this “solution” remains vexed by problems it cannot solve. First, contention continues over what and who counts as “the environment”—since entities comprising “not genes” can variously extend anywhere from non-DNA molecules within cells to macroeconomic systems.25 Second, in the case of living beings, “genes” don’t interact with environments: organisms do.26 While analysis of literally disembodied genes (as well as genes inserted from one type of organism into another) can be designed and executed in laboratories, that is not the same as the lived experience of genomes becoming expressed as emergent embodied phenotypes.27 The seeming “concreteness” of seemingly apolitical “genes” versus the “fuzziness” and perhaps more readily politicized “environments,” and the greater possibilities for the “manipulation” of the former versus the latter by empirically oriented health scientists, means
that “genes” consistently get first seat for funding and causal attention.28
Beyond this, GEI founders on the terms of debate set by the first explicit partitioning of “nature versus nurture” as propounded in the late 19th century CE by Sir Francis Galton (1822–1911)— an English Victorian elite investigator who came down squarely on the “nature” side and, related, coined the term “eugenics.”29 Since then, endless debates, in and outside of public health, have vigorously disputed which matters more.30 One repeated and profoundly erroneous exercise has been to try to apportion the respective causal contributions so that the sum adds up to 100%—for example, 10% genetic, 90% environmental, or 70% genetic, 30% environmental.31 These exercises, however, profoundly and wrongly ignore what interaction entails. Specifically: interaction—whether between “genes” and “the environment,” or between multiple genes, or between different components of “the environment”— by definition means the sums must add up to more than 100%.32
It is not a new insight that taking interaction seriously requires understanding that “nature” and “nurture” cannot be neatly partitioned. In the 1930s, Lancelot Hogben (1895–1975), a prominent medical statistician, experimental zoologist, and population geneticist, first formally introduced the fundamental concept of the “interdependence of nature and nurture.”33 He demonstrated mathematically, and with real-world data, that the very question of “which matters more” is at its core fallacious. If, say, a plant and its clones on average grow only 3 inches tall in soil type A, but its numerous clones on average grow 6 inches tall in soil type B, then there is not one answer to how tall a plant will grow, given its genome, because it depends on context. By implication, if two
