Health, Risk, and Adversity

By Catherine Panter-Brick and Agustín Fuentes

Research on health involves evaluating the disparities that are systematically associated with the experience of risk, including genetic and physiological variation, environmental exposure to poor nutrition and disease, and social marginalization. This volume provides a unique perspective - a comparative approach to the analysis of health disparities and human adaptability - and specifically focuses on the pathways that lead to unequal health outcomes. From an explicitly anthropological perspective situated in the practice and theory of biosocial studies, this book combines theoretical rigor with more applied and practice-oriented approaches and critically examines infectious and chronic diseases, reproduction, and nutrition.

• Language: English
• Publisher: Berghahn Books
• Release date: Nov 1, 2008
• ISBN: 9781845458713

Book preview

INTRODUCTION

Health, Risk, and Adversity

A Contextual View from Anthropology

Catherine Panter-Brick and Agustín Fuentes

Health and Adversity

Both anthropology and public health have focused extensively on the question of who suffers from poor health outcomes. Both fields are still developing ways to examine why and how health differentials emerge over the lifetime of individuals. This book aims to enhance understanding of outcomes and processes that govern relationships between health, risk, and adversity—to facilitate linkages between multiple levels of inquiry, into who or what brings about health disparities, as well as into how, when, and why differential health outcomes occur.

As editors, our goal is to relate the risks of poor health to contexts of adversity, defined as social or physical environments that create hardship or affliction. Health and risk are words that have entered the everyday language of many contemporary societies (Beck 1992; Lupton and Petersen 1996; Douglas 1997; Lupton 1999; Boyne 2003). Why should these two terms be linked to adversity? Adversity matters to health because it is responsible for human suffering on a scale that demands both objective research and ethical intervention. Most adverse environments are due to human action or inaction; most sources of ill-health are liable to remedy or prevention; and most health differentials across human populations are demonstrably unnecessary, avoidable, and unjust (Whitehead 1992).

Health is a state of complete physical, mental and social well-being, according to the World Health Organization. This definition is uncannily similar to that of happiness, but with an important difference: health is ratified by the United Nations as a universal human right, happiness is not (Saracci 1997; Panter-Brick 2003; Ross 2006). Systematic disparities in health across populations are currently a high priority for the international public health agenda (WHO 2008). The focus is on major health inequalities across socioeconomic groups, and, where closely aligned with a human rights approach, on health inequities produced by social advantage or disadvantage (Braveman and Gruskin 2003; Casas-Zamora and Ibrahim 2004)—namely, the avoidable and unjust distribution of resources with respect to gaps between health-related needs and service provision (Carter-Porras 2002). Addressing inequities is a vital mandate in the public debate about health (Editorial, Lancet 2008; Marmot, 2007).

Health disparities are unmistakable evidence of significant life adversity. They permeate human experience across a whole range of sociocultural contexts, ecological settings, and developmental trajectories. Such disparities are often conceptualized and evaluated under the rubric of risk—in this book, we examine experiences of risk associated with genetic and physiological makeup, environmental exposure to poor nutrition and disease, and social marginalization. Vulnerability, susceptibility, and adversity are key constituents in this investigation, whether pertaining to the issues of risk measurement, risk evaluation, or risk communication.

Anthropology as Context

Anthropology provides meaningful conceptual frameworks and diverse methodological tools for health research. Within this field, a comparative approach is used to examine health experiences across space and time. Anthropology as an academic discipline is currently differentiated between bio-evolutionary and sociocultural fields, with medical anthropology in an interstitial position (McElroy and Townsend 2004). Thus, several conceptual frameworks are in existence. For biological anthropologists, health risks and health outcomes across populations are shaped by the expression of genetic inheritance and the relative fitness of individuals confronting environmental challenges over evolutionary time (Stinson et al. 2001). For social anthropologists, health risks are dimensions of experience as well as behavior, which derive meaning from a shared cultural model or competing social constructions of hegemonic and lay knowledge (Popay et al. 1998; Krieger 2001; Loch and Nichter 2002). A common ground is advocated by researchers promoting systematic ways of relating biology with culture, to critically evaluate health disparities within and between populations in terms of political economy and social structure (Goodman and Leatherman 1998; Hahn 1999; Helman 2001; Kaplan 2004; Dressler 2005; Leatherman, 2005; Dufour 2006).

These approaches provide a powerful complement to epidemiological mapping of health risks in terms of webs of causation (a metaphor referring to the numerous, interrelated risk and protective factors related to disease), in providing a critical evaluation of the spiders—agents responsible for spinning the web in the first place (Krieger 1994). Health risks do not simply appear in a web of complex, interrelated factors; they are produced or reproduced by social agents, hegemonic structures, or ecological pressures. A factorial analysis of health risks without critical explanation has limited appeal (Parker and Harper 2006), even if it does pave the way for public health action. A better understanding is required of the processes through which health disparities emerge across space and time—an understanding of how health risks are spun (Figure A).

Collaboration across Disciplines

Few would disagree that effective collaboration across disciplines enables better understanding of the processes governing the emergence of health risks in adverse living conditions: no single discipline has a monopoly of insight (Parker and Harper 2006:1). However, what exactly does collaboration mean? How is it fostered in research or applied contexts (Lambert and McKevitt, 2002; Porter 2006)? White's concluding chapter to this volume illustrates some of the difficulties of talking across disciplines or bridging methodological practices, but emphasises the value of interactions across applied and academic domains. The academic steps involved in health research are akin to working on a puzzle, where individual players initially focus on particular areas, find critical missing pieces, rectify faulty moves, and contribute as a team to decipher the overall picture. Cross-disciplinary collaboration is far more compelling than any single discipline for revealing specific links between health risks and adversity.

Figure A. A web of causation representing interrelated risk and protective factors, with the agent (a spider) responsible for their root.

Research involving a cross-disciplinary, cross-cultural study of health risks and adversity often involves collaboration between different institutions—academic, political, nongovernmental, advisory committees, and other professional agencies—on an international scale. Collaboration of this nature introduces additional complexities: financial constraints, linguistic barriers, negotiation of research permission and ethical issues, different expectations about fieldwork practices, and varied access to published literature or analytical software. Health research must thus accommodate a diversity of conceptual frameworks, a dialogue between research and intervention, and institutional collaborations on an international scale.

Architecture of this Book

This book is divided into three main sections: health risks and diseases in transition; generational and developmental change; gene evolution, environment, and health. Each section has three chapters, written by biological and medical anthropologists, epidemiologists, and/or clinicians. Three discussants, from the fields of archaeology, human biology, and sociocultural anthropology, provide introductory analysis and commentary to these sections. The concluding chapter, written by an expert in public health, provides an overview of the contributions, highlighting the strengths and weaknesses in the approaches exemplified in this book.

This format serves as a thematic and a pedagogical tool. We refer readers to the commentaries (by Charlotte Roberts, Darna L. Dufour, and William W. Dressler) and the conclusion (by Martin White) for elegant expositions of take-home messages and critical evaluations of individual chapters. Our own emphasis, in this introduction, is twofold: we draw attention to how narratives permeate cultural discourse and scientific inquiry on health, risk, and adversity; and highlight conceptual approaches for evaluating people's lives in the context of social, ecological, and evolutionary change. In our view, health research is at its best when it engages with both the discourse and the science evaluating health risks and adversity.

Risk Narratives

Risk narratives are story lines or discourses that weave together cultural and scientific accounts regarding the conceptualization and communication of health risks, or relative vulnerability to poor health, in personal lives, media reports, political directives, and expert accounts. Narratives play central roles in our understanding of adversity and risks to health: indeed, they are a core component and often a problematic aspect of health research and public health policy (Oaks and Harthorn 2003; Bennett and Calman 2005; Porter 2006). Writing about vulnerability to avian flu or influenza, Herring (Chapter 3) states the fact that narratives have a powerful influence on public concern about health crises and health policy…it is important to identify and critique the narratives and moral lessons that run through scholarly and media discussions of epidemics. A preoccupation with emergent diseases is a good example of a risk narrative that took on global significance when Western populations began to experience risks of contagion, of the kind that had long been suffered by indigenous people in their local contexts, for example multi-drug resistant tuberculosis (Hurtado et al. 2005; Farmer 1999). Indeed, Farmer took to task the public health policy, resource distribution, and professional commentary on emerging infectious diseases, as based on a rhetoric of risk for Western populations—to the detriment of those who have been silently suffering with these diseases, often for generations (1999, p. 57).

We invite our readers to evaluate the ways in which risk narratives shape our understanding of the links between health, risk, and adversity. In this volume, narratives are explicitly associated with hype about primate-borne infections and human pandemics, epidemics, and smaller-scale crises, by Jones-Engel and Engel in Chapter 2 and by Herring in Chapter 3. They are insidiously linked to ethnic categorization and social profiling of hypertension, by Madrigal et al. in Chapter 9, and shown to guide investigation into the real or hidden risks to child health, by Sellen in Chapter 6. Risk models and multifactorial analysis may seem empirically grounded in objective scientific inquiry. Yet the representation of risks factors as a web of causation is bound in a cultural story, a discourse that structures the measurement of risk factors, the communication regarding genesis of health disparities, and the promotion of health interventions and public health policy. Even the explanatory frameworks invoked in this volume—such as evolutionary theory, developmental origins, or acculturation—are, to a degree, narratives that weave together complex elements of biological and cultural processes responsible for health.

Risk narratives also take the form of social categorization. In the field of public health, risk factors are variables that expose or predispose individuals to illhealth: the assessment of risk usually proceeds from the statistical measurement of factors that affect health and well-being. The quantitative approach to risk is a matter of ordering reality in a calculable form, to help assign individuals into low-risk or high-risk categories (Dean 1999, pp. 143–44). Such at-risk categorization understandably permeates biomedical practice (e.g., decisions for hypertension treatment are guided by blood pressure thresholds demarcating risks of health and disease). We fall prey, however, to problematic generalizations, if a categorization of individuals leads to flawed policy or social marginalization (see Panter-Brick 2002 for homeless children, Parker 2006 for sex workers). An empirical, probabilistic statement is readily transformed into a normative, deterministic statement regardless of historical context. In this book, this is well illustrated by Madrigal et al. (Chapter 9), who show a deceptively simple scientific hypothesis—black skin as a risk factor for hypertension—to be deeply flawed both in terms of evidence and as a conceptual model. Because risk is both a statistical notion and a social categorization, anthropology makes a significant contribution to analysis, by coalescing the scientific evaluation of health processes with a critical appraisal of health outcomes in social context.

Conceptual Approaches

The commentators in this book (Roberts, Dufour, and Dressler) review the material offered across chapters in ways that call attention to conceptual frameworks and contextual analyses of health risks and adversity. Roberts draws a parallel in the study of past and present human populations, between archaeological approaches, used to appraise diversity of skeletal or cultural archaeological material, and the evolutionary and biocultural perspectives developed in this book. Archaeologists also make use of risk analysis to appraise the relatively unknown processes through which health disparities develop over evolutionary time. Dufour usefully critiques the use of the term environment, which in the broadest sense encompasses all the living conditions of a population, including physical, social, and cultural context. We often talk about environments without specifying which features of the environment or environmental change are actually relevant to people's lives. To reach a better understanding of health contexts, it is necessary to specify which features in our environment produce disparity in health outcomes. Dressler opens his commentary with a focus on the terms health inequalities and health disparities, vocabulary currently espoused in the UK and the USA respectively. He reviews how this area of research is enhanced by biocultural research in anthropology. He warns, however, that we must take the concept of culture seriously, culture as defined by shared meaning regarding belief and behavior. As editors, we think that health researchers could all go a step further, by showing a deeper appreciation of biology, behavior, ecology, and culture.

This book contains clear examples of why health risk research requires careful attention to scientific enquiry and cultural discourse. Consider the contributions on obesity and cardiovascular health by Leonard et al. (Chapter 1), hypertension by Madrigal et al. (Chapter 9), breast cancer by Núñez-de-la-Mora and Bentley (Chapter 5), psychosocial stress by McDade (Chapter 8), and growth retardation by Sellen (Chapter 6). These chapters employ terms widely used in risk modelling and discourses about risk or adversity: socioeconomic status, ethnic group, environment, modernization, lifestyle, and socioeconomic transition. Such well-worn constructs serve in analyses of health across place and time, but more often than not they have no simple ethnographic or ecological basis. As McDade aptly shows, there are multiple dimensions of status in existence even on a relatively small island, with potential mismatch of social and economic experiences linked to heightened psychosocial stress. Leonard et al. explicitly demonstrate, with reference to populations in Siberia, that relationships between lifestyle, metabolism, and cardiovascular health are multifaceted, given the context of major geopolitical changes and socioeconomic transition. Our contributors model risks to health against a backdrop of evolutionary, developmental, ecological, or social change—it is change that facilitates comparative analyses of health and adversity. They draw upon a strong anthropological tradition of comparative and contextual analysis, in their examination of life trajectories over evolutionary time, during growth and development, and under ecological and social change.

Professional outlook and definitions give rise to important issues in health research and practice. In Chapter 4, Ellison and Jasienska reflect upon the conceptualization of health in reproductive ecology, a field of interest to biomedical practitioners as well as anthropologists trained in evolutionary and ecological paradigms. If we are to understand the production of health differentials, we require a consistent usage of terminology, such as adaptation and adaptability, two fundamental constructs in human biology. Many textbooks, for example, envisage adaptation—defined as a beneficial response to environmental adversity—solely in biological terms, while others relate it to both biology and behavior. Understanding of adaptation is often dangerously tautological: evidence of adaptation is linked to success in overcoming a difficult environment, while success is all too easily attributed to adaptation. Assessment is made all the more difficult given the human capacity for niche construction (modifying and creating environments, Odling-Smee et al. 2003), which alters the patterns and types of ecological pressures on populations. The concept of adaptability—flexibility in the face of environmental adversity—has even greater significance for human life, since most life trajectories negotiate a great deal of change; but it is also more challenging to document in the case of humans. Adaptability involves complex, interacting responses, with costs and benefits manifested not just as immediate trade-offs, but over the lifetime of an individual and across several generations (Kuzawa 2005). Making judgements about trade-offs is difficult; a response is deemed adaptive only if benefits outweigh potential costs. This was evident in debates rejecting the small but healthy hypothesis (children have reduced body size under conditions of food scarcity, enhancing short-term survival but entailing longer-term risks to maternal-child health and work capacity [Martorell 2000; Norgan 2000]).

The power of this evolutionary conceptual framework is nonetheless widely recognized, not just within anthropology but in other health-related fields. For example, Godfrey and Hanson are clinicians who review the significance of predictive adaptive responses in early human development, in engendering health disparities in later adulthood (Chapter 7). Their evaluation of physiological processes, contingent on a mismatch between uterine and later nutritional environments, as well as critical evaluation of the magnitude and timing of physiological trade-offs, provides us with a complex example of human adaptability. This moves us away from reductionistic models of genetic inheritance that envisage only linear impacts of natural selection, a static or tautological definition of adaptation, and a simple binary definition of health and disease. Godfrey and Hanson demonstrate the complexities of fetal development across multiple physiological and social contexts, to show that genetic makeups and environmental contexts interact over the course of a lifetime. Again, the adaptive or maladaptive nature of fetal responses is difficult to demonstrate (Jasienska et al. 2006), while the mismatch between early and later environments remains ill-defined. Clinical health research here draws closely on modern evolutionary theory to understand the processes by which humans and their environments (writ large) shape one another to produce critical health outcomes for mothers, babies, and later adults.

Our contributors also highlight methodological challenges in health measurement across time, place, geography, generations, and families. They seek to identify the processes that generate poor maternal, fetal, infant, child, and adult health outcomes, responsible for associations between health risks and adversity. The tracking of migration and acculturation patterns, maternal physiology and behavior, and fetal health and the very specific social contexts in which growth and reproduction takes place requires not just integration of biology and culture but longitudinal assessment. Research that follows individuals across their lives, the lives of their parents or spouses, and their acculturation to novel environments demands a long-term investment of money, time, and energy. Throughout this book, there is a call for identifying measures in the short-term that can reliably predict health risks in the distant future, for example by using growth status to foresee critical threats to child health (Sellen, Chapter 6), and by using developmental markers to predict breast cancer (Núñez-de-la-Mora and Bentley, Chapter 5). There is also systematic reflection on when and how to intervene to bring about significant, population-wide improvements in well-being—for instance, to improve maternalfetal interactions, which Godfrey and Hanson argue (Chapter 7) provide the most effective opportunity for large-scale public health intervention.

Audience and Pedagogy

We address this book to social science and public health researchers who, like us, are guided by the simple principle that health matters. Some authors have included a brief description of their own research trajectories, interests, and/or reasons for pursuing research in their field—a personal narrative to encourage reflections on the research process. The chapters include boxes (in text or chapter appendices) that summarize take-home messages, enhance discussion, expand on particular topics, present thematically related information, or illustrate central concepts. These boxes thus serve for quick reference, additional information, clarification, and, from the standpoint of pedagogy, as foci for discussion or further investigation. Terms and concepts requiring definition are featured in the glossary.

We hope that this volume will engage both researchers and students, appealing in content and style. The chapters express multiple viewpoints, with perspectives that may differ or overlap—this is an important component of research endeavors. Such perspectives highlight our current state of knowledge and practice in a contested field, but they also demonstrate that research itself is an ongoing dialogue.

We wish to thank the Wenner-Gren Foundation, the University of Durham and the University of Notre Dame Institute for Scholarship in the Liberal Arts for partial support of the original discussions leading to the essays in this book.

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PART I

Health Risks and Disease in Transition

Understanding Health

Past and Present

Charlotte Roberts

It is hard for people to know if things are getting better or worse.…there is the myth of progress, which claims that technological innovation makes our lives less grueling, healthier, more productive, and happier…[and] there is the myth of the good old days…

—G. J. Armelagos (1998:59)

The Complementarity of Studying the Living and the Dead

As a person who does not research health in living populations, I find that this book not only provides fascinating and incredibly useful insights into living populations—that is, how we might approach evaluating how and why people get sick—but also shows how relevant medical and biological anthropology are to our understanding of the origin and evolution of disease over long periods of time. Palaeopathology, biological anthropology, and medical anthropology complement each other nicely; while palaeopathology can provide a window on disease evolution over long periods of time and highlight the main reasons for the appearance of specific diseases (Roberts and Manchester 2005; Larsen 1997), biological/medical anthropology focused on living populations can provide a better context for the many factors responsible for disease occurrence in populations today (McElroy and Townsend 1996; Sargent and Johnson 1996). Approaches to understanding health that are broad, holistic, and interdisciplinary, that emphasize the health implications of interactions between humans and their physical and biological environments, are something for which we should strive in palaeopathology, biological anthropology, and medical anthropology. The anthropology of modern populations, like palaeopathology, considers people in many environmental and cultural settings ranging from isolated and marginalized locations to urban community settings. However, one common difference is that in palaeopathology there can be a tendency for the study of disease for its own sake with no consideration of the factors causing the condition observed, and a concentration on individual skeletons rather than populations, often with an emphasis on just one geographical location (e.g., Anderson 1997). In medical and biological anthropology of modern populations, this approach is usually avoided.

It is surprising how many of the approaches seen within the three sections of this volume (Health Risks and Diseases in Transition; Generational and Developmental Change; Gene Evolution, Environment, and Health), have been followed in palaeopathology. However, palaeopathologists still have much to learn from biological and medical anthropologists about the impact of the many variables determining health status in the living. Researchers in past human health tend to come from diverse backgrounds (anthropology, archaeology, medicine, dentistry, nursing, anatomy, public health), but, more often than not, they lack an appreciation of the real impact of health problems on people living in the past because their dataset consists of observations from skeletal remains, often with no consideration of the association of signs and symptoms with the disease changes they observe. Furthermore, until recently, methods of analysis have been limited, and it has not been possible even to attempt to answer some questions about past health with the analytical methods available (although times are changing—see Brown 2000 for a commentary on ancient DNA analysis). However, there has always been some attempt, more often in North America, to consider past health both in the context of the origin and evolution of disease, and the socioeconomic and political factors relevant to a disease's appearance and maintenance (see, e.g., Walker and Hollimon 1989; Merrett and Pfeiffer 2000). While advocating this approach, it must be acknowledged that it is often not that easy to apply when studying a sample of skeletons from an archaeological site that are often fragmentary (making diagnosis of disease very difficult), and with no knowledge of whether that sample is representative of the health of the original living population from the region (see Waldron 1994, and Wood et al. 1992, for a detailed discussion of the problems of inferring health from skeletons). Additionally, for most, there are limited analytical methods (usually restricted to diagnosis of disease that affects only bones and teeth) and sociocultural contextual data may be incomplete, making a biocultural approach to palaeopathology difficult. However, we make the best of what we have (Roberts and Cox 2003), make recommendations for future work, and hope things will improve. There are similar problems with collecting and interpreting data in the fields of medical and biological anthropology, although anthropologists who focus on living populations are better placed to investigate health risks under adverse environments.

Diseases and Transitions

Health and disease are measures of the effectiveness with which human groups, combining health and cultural responses, adapt to their environments (Lieban 1973:1031).

The theme of this section, Health Risks and Disease in Transition, has been tackled in palaeopathology by some scholars for some time now (see, e.g., Swedlund and Armelagos 1990). Our ancestors experienced a change in their ecological relationships with the advent of hunting and gathering, pastoralism and nomadism, settled agriculture, and urbanism and industrialization, all with their attendant health problems; the developing complexity of life is viewed as broadly detrimental to health (see, e.g., Cohen and Armelagos 1984; Cohen 1989; Roberts and Cox 2003; and Steckel and Rose 2002). However, Froment (2001) has highlighted the problems of inferring health from skeletal remains, as illustrated in more detail by Wood et al. (1992). For example, even thought skeletal remains of hunter-gatherers may appear more healthy than those of settled agriculturists, there is a possibility that they may have died from diseases that did not affect the skeleton, or they could have died before disease had chance to make its mark on bone. Froment further indicates that nonsedentary groups will be more at risk from exposure to specific epidemiological risks such as closer contact with wild animals and more violent deaths through hunting and other accidents. Nevertheless, it is suggested that the contexts of hunter-gatherer groups in the past and present are radically different (Froment 2001:259). Clearly, there are different health risks for people around the world that are influenced by a variety of environments and economies, and these risks will have changed through time.

Armelagos (1998) describes three major epidemiological transitions: the transition to agriculture, the post-World War II development of antibiotics to treat infectious disease, and the reemergence of new diseases as a consequence of changes in our environment (including the mutation of pathogens to resist pharmaceutical remedies). However, transitions and change can be very gradual and slow, with people experiencing different worlds at the same time (something that is true for living populations). Clearly, though, the dominance of the degenerative diseases in patterns of morbidity and mortality today, certainly in developed parts of the world, is being affected by emerging and reemerging infections.

The topic of health risks and diseases in transition has been interpreted broadly in this book, but the focus is on the risks of human populations to disease as their living environment changes through (mainly short) periods of time. Much has been written on this theme, which includes the impact of the movement of people to new environments (whether it be for trade, tourism, or to potentially gain a better life—see, e.g., Mascie-Taylor and Lasker 1988; Roberts et al. 1992; Wilson 1995) and the consequences of socioeconomic change on disease loads in human populations (see, e.g., Cohen 1989; Morse 1995). For example, one of the many factors in the rise of tuberculosis today is increased mobility of human populations; Davies (1995) claims that immigration is one of the single most important causes in increases of TB in most developed countries. Likewise, malaria has seen a global resurgence as a consequence of many factors, not least the impact of particular agricultural systems on the ability for mosquitoes to survive and reproduce (Brown 1997). Of course, humans have a great ability to adapt to changing circumstances. If adaptation means survival, then the human body needs to develop coping mechanisms whether these are cultural or biological, including genetic (through natural selection over a long time) and physiological (over the person's lifetime) mechanisms. Clearly, this phenomenon has occurred in the past and continues to occur today.

The chapters in this section are wide ranging in their treatment; they consider:

•   cross species transmission of disease, particularly primate-borne zoonoses in Asia, and the consequences for human populations (Jones-Engel and Engel);

•   the possible global impact of avian influenza, its relevance to the 1918 influenza pandemic and the potential of cross-species transmission from bird to human (Herring)—an issue that is very topical; and

•   the impact of evolutionary (cold exposure) and adaptive (changing economy) responses of indigenous Siberians on cardiovascular disease rates (Leonard, Snodgrass, and Sorensen).

The chapters cover diseases both of an infectious and of a chronic degenerative nature. The latter is illustrative of people living in both developed and (increasingly, more recently) developing countries as a result of greater exposure to a lifestyle, in its broadest sense, that is conducive to chronic degenerative diseases (as indicated by research by Eaton and Boyd 1999 and by the chapter by Leonard et al.); the former tends to be more common in developing countries due to a set of particular circumstances, not least of which is a poor living environment and problems with access to health education and care, such as antibiotic therapy (although, increasingly, infectious diseases are being seen in the developed world). Both are indicative of our changing world and highlight where we have made mistakes, what risk factors we should look out for in the future, what we might do to address those mistakes, and whether the measures taken will be effective. It is a sad fact that it is usually when the developed world encounters a health problem that serious action to combat it is taken.

Each chapter in this section illustrates the complex evolutionary and adaptive relationship that humans have with their changing environments, clearly emphasizing that the changes humans create in their environment can have grave implications for their health and well-being. Herring (Chapter 3) clearly illustrates the impact of factory farming and developed trade networks on avian influenza transmission. All chapters also remind us that the epidemiology of disease is highly complex, and that to conquer these diseases multiple factors need to be taken into account with people from different disciplines needing to work together to achieve that aim (as illustrated well in Jones-Engel and Engel in Chapter 2). While the medical profession and public alike thought some diseases such as TB had all but disappeared in the 1980s (e.g., Smith 1988), some conquered diseases are reemerging and totally new pathogens have also evolved. The journal Emerging Infectious Diseases first appeared in 1995, which perhaps illustrates the increasing awareness of the problem of infections. For example, we have seen tuberculosis and SARS (severe acute respiratory syndrome) spread from human to human via droplet infection through travel, trade, and contact around the world, the impact of developments in the food industry and increased eating out in restaurants on the frequency of food poisoning (e.g., in the UK), and the effect of increased, and inefficient, use of antibiotics to treat infection, leading to antibiotic resistance in some pathogens (e.g., MRSA or methicillin resistant Staphylococcus aureus in UK hospitals; see Barrett and O'Hara (2005) on the 25th anniversary of the Journal of Hospital Infections).

Cross-species Transmission of Disease

In these chapters a number of observations emerge