Overlaps, Disjunctures and Possibilities: Evolutionary Anthropology and Medical Practice in Conversa

Agustín Fuentes & Eleanor Lisa Lavadie-Gómez

In the midst of the COVID-19 crisis, the complexity of human health in the 21st century is anything but straightforward. We know human beings evolve and integrate with and in their surroundings via a complex suite of physiological, behavioral and cultural patterns,1 but that is not how “health” is generally conceived in most medical training and practice. For a number of historical and practical reasons, much of the medical world views the human body through the lens of the “broken car model,”2 where dis- ease, dysfunction and departures from homeostasis are largely seen as parts breaking down and needing to be fixed, altered or modified, often via pharmacological means. Though there is much good from this system, it is flawed. Many anthropologists, sociolo- gists and a range of physicians have argued that there is a need to augment and expand on this conceptualization of health to facilitate a baseline perspective wherein a diverse spectrum of patterns and processes, both in- side and outside of the body, map to a range of sufficient outcomes and work synchronously to maintain health. Such an approach extends beyond the traditional and narrow biomedical duality of health vs. disease and moves closer to a more effective understand- ing of the dynamics of human health in the 21st century.

Across the end of 2020 and into 2021, an evolutionary anthropologist, Agustín Fuentes, and a practicing physician who also teaches at a medical school, Eleanor Lisa Lavadie- Gómez, reflected together about the state of medicine and health. The two brought their individual training, experiences and perspectives to think with and about health and health care, specifically considering the benefits, complexities and possibilities of a greater entanglement between anthropological data and perspectives and medical training and practice. This is a well-trodden road, with a long history of interactions among anthropologists, doctors and biomedicine, yet much of the potential in such discourses remains just that potential. This is a critical moment for the medical establishment in the United States. The COVID-19 pandemic has cast a spotlight on the many structures and practices of inequity in health care. A diverse array of doctors, social scientists and health practitioners are responding in what appears to be a more substantive and potentially game-changing manner than ever before. To keep up the momentum for change requires constant, consistent engagement in reflection, action and education. This moment should not, as so many others have, pass into the rearview mirror without having reshaped the present and future.

The dialogue between anthropology and medical practice offers a place, a context and a set of possibilities for renewed, more just and more effective understandings and practices of health. But such dialogue need not always take on the formal trappings of scholarship, research or traditional pedagogy. Sometimes, just talking about a topic, without the confines of academic jargon and exam-oriented factoids but with immersion in the core realities of practice, can act to facilitate a resonance with, and for, transformation. Here we offer one such conversation as an example of where we can be thinking, and acting, right now. In this exchange, an anthropologist and a doctor think together about change, in practice and in training, with an eye toward an audience of students and colleagues. Our conversation is a reflection of what we hope is an increasingly common trend across the landscape of pre-med programs in universities and first- and second-year curricula in medical schools.

However, we acknowledge that such an in- vestment in critical reflection and progressive engagement is likely not yet a majority pattern/practice. Therefore, our goal with the conversation that follows is to interest students and instructors, researchers and curriculum planners, anthropologists and doctors in delving more deeply into these themes and perspectives by seeking out collaboration and building community.

Image 1. Illustration by Carla Keaton. To see more of Carla’s original work, visit keatonfinearts.biz.


Agustín: The first question we have in front of us is why the so-called broken car model might not be sufficient for the most effective path to health and wellness. The broken car model is a critique of the compartmentalized approach to health, the idea that the human body is a machine and that when illness, disease, is impacting the body the target should be the “parts” or manipulation of the system. It is the assumption that adding something restores quality to the “part” in focus, rather than thinking about the system as a full set of interconnected parts in interconnected, dynamic relationships.

We see systemic patterns of health in, say, diabetes, a variety of stress-related illnesses and a range of traumatic impacts on health from diverse sociocultural, ecological, developmental and experiential contexts. The idea that we can treat the specific part that is malfunctioning or “broken” by bringing the body into the shop, fixing the body, putting it back out and it will work — that’s the broken car model. I think that’s a problem. What do you think?

Lisa: I think it assumes there are two extremes, either “well” or “not well,” and nothing in between. What we don’t acknowledge is that the biodiversity emerging from social, economic and a range of other contexts means that one person with diabetes is not going to have the same response as another person with diabetes. Diabetes is a good example because many of my patients have this chronic condition. There is a measure of blood glucose control called hemoglobin A1c. An ideal level is less than 7 percent, and values above 7 percent are known to cause organ damage. One patient may have an A1c at 13 percent and still have normal sensation in their toes, and another may have an A1c of 9 percent with significant burning on their feet from peripheral neuropathy. In such a case we might not be accounting for the duration of the disease, the way that the disease presents given specific genetics, family history, specific social contexts and other comorbidities such as tobacco abuse, alcohol abuse. I think that’s why we can’t use that broken car model; there’s too much variation across individuals, even with the same “broken” parts.

Agustín: I think you’re absolutely right, and I would emphasize clarity in two places. One is the social context. Social actions are made in a landscape of affordances and constraints, the social structure and the reality of that individual. While social decisions affect health in this context, what the options are for those decisions also affects health.

The second thing is the genetic background. Obviously, individual genomes have huge impacts on our understanding of the patterns and process of physiological, endocrine and a variety of other bodily systems that impact health and may be relevant in disease response. But the idea that we can group or understand genetic variation through race or ancestry is highly problematic because it’s much more complicated than that. Genetics matter, but not the way most people think they do.

We will return to this key theme, but let’s spend a little more time with the concept of “health.” Defining health is a complex challenge. In the past, I’ve had conversations with doctors who do great targeted work, fixing “parts” of the body. They say the rest of “that stuff” — the bodily systems and social contexts key to overall well-being and understanding health — is not their problem. So many in the biomedical realm believe the key is to fix the part of the body that is not “working” and cumulatively add fixes to other parts so that the body is “fixed.” But should this be all doctors do? Is it enough to get the body back on the road?

Lisa: Let’s consider the roots of some important words. “Heal” is part of the word health. The World Health Organization [WHO] has a statement,3 unrevised since 1948, that reads as follows: “Health is the state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”

Disease comes from the old French desaise or lack of ease/convenience. Generally, if we’re thinking about disease in the way the biomedical world contextualizes it right now, we think of it as something broken, something wrong. If one then considers “lack of ease,” we are forced to reflect on a broader definition that suggests disequilibrium within a system. That may include a spectrum of outcomes and not just the binary of “good” and “bad.” I think focusing on the etymology of those words can broaden the focus of how we think through the differences between health and disease.

Agustín: That whole concept resonates so well with contemporary thoughts about the social determinants of health. I actually have a slight problem with this phrase because I prefer to say the social, ecological and biological determinants of health, as it’s always all of those things interacting. I think that’s what the social determinants of health means. This is why it seems to me that medical professionals, particularly those individuals involved in teaching medicine and forming medical students into doctors and a diverse array of practitioners in other medical-related fields such as public health and nursing, should be in dialogue with anthropology writ large. This facilitates an understanding of human evolution, of human behavior, of different cultures and cultural processes. It means taking complex, deep understanding of the patterns and processes of daily lives as a baseline. And as you pointed out with your patients’ A1c examples, this is relevant. But such a perspective does run up against giant obstacle: one can’t do everything. Medical practitioners can’t connect all these dots all the time. In this light, what kind of dialogue can one have training medical professionals if we’re going to think about health in the way WHO put forward in 1948? What are some of the things we need to think about?

Lisa: I’ve been in practice for 10 years, and I think often about what makes a successful physician or health care provider. The people I admire are the ones who are willing to admit some uncertainty and vulnerability, who are not afraid of stating, “I don’t know.” I’m in the process now of reviewing medical school applications as a member of an ad- missions committee. When one looks at the type of person who pursues medicine, there are patterns of altruism, patterns of determination, grit, working against all obstacles. Sometimes, however, I think the contemporary medical school training beats that out of them, and they leave medical school feeling overwhelmed, feeling almost as if one has to be perfect and can’t be wrong. It takes a lifetime of medical career and working to realize that one is a better doctor when able to admit vulnerability, that “I don’t know the answers” and there is a spectrum of wellness that isn’t simply the binary “sick/well.”

Agustín: That is such a wonderful way to conceptualize this because it is unfortunate that when the medical and academic worlds think about health, we see it just like every biological process and we teach that the strive toward optimality is best/ideal. But that’s not true. Life, bodies, systems most often achieve sufficiency, homeostasis. And the homeostatic moment is rarely optimal in any organism. There are many successful ways to be human. Why should we expect optimal functioning (whatever that might mean) in humans? Why should we expect perfection from bodies, and from doctors? What if the training of people who deal with health was clearly structured in such a way that optimality and perfection are not the goal but knowledge, understanding and flexibility are? The possibly of “Hmm, I don’t know. Maybe we need to consult with others” can be a part of training. And this is not just in reference to specialists but also others who might be generalists but with different experiences.

Lisa: I think what my training in family medicine affords is a broader perspective. I don’t see people as composites of organ systems. I see them as wholes made of many systems that work together, sometimes congruently, sometimes incongruently. Often because of our medical training that focuses on pharmacological cure or pharmacological improvement, people come to doctors seeking perhaps that one quick fix that will erase whatever difficulty they are having. There are various forms of “disease” that one can’t see on an x-ray; maybe it’s alcoholism, maybe it’s substance abuse, maybe it’s social psychological trauma. It’s a very complex web. In my conversations with patients who have chronic diseases, we often go back to central themes of loving themselves, accepting vulnerability and accepting that this might be their new normal but focusing on how they can still live a meaningful life according to their own personal definition of “meaningful.”

This goes again to what you just said: “There are many successful ways to be human.” The statement resonates with me be- cause maybe for those people who have undergone something significant in their life, where one loses the ability to walk or the ability to activate a sense that they previously had, there’s a strong desire to want to push forward, to strive to accomplish something and to make a meaningful contribution as a human. To live a life.

Agustín: That’s absolutely true. I think particularly in our society, but in many societies, there’s a very harmful perspective of optimality or the best way to be normal. There are some wonderful scholars; for example, Ranya Rapp and Faye Ginsburg have put out an issue of the journal Current Anthropology4 on critical disability studies, which is a wonderful sort of approach to thinking, wait, what do we mean by “normal”? What is the range of possibilities and successful ways to be human? That’s not the undergirding approach in medical training. … Isn’t it more like, “These things are broken. Here’s how you fix them”?

Lisa: Right. I think it’s changing slowly. We’re transitioning even the way we refer to patients by using person-first language. We are not saying Miss Smith, a 44-year-old obese patient with diabetes and hypertension. Instead, we say Mary Smith is a 44-year-old patient with obesity, diabetes and hypertension. It’s important to use person-first language as opposed to defining people by their medical conditions.

I think such a practice informs how students of medicine will start to incorporate those ideas as they become physicians. If one sees a patient as a disease rather than as a whole person, the training and focus are going to be narrow. As practitioners mature and widen that focus, they start to see the individual and realize, “Okay, this is the person. This is a whole person.”

I recently saw an adolescent who is struggling with depression and anxiety. I reminded them, “You are a whole person. You are not broken. It’s just that your mind reacts to stressful situations in a way that makes you vulnerable.” One can see the tears rushing out of such patients’ eyes when they are told, “You’re a whole person,” because often the message they’re hearing is that they are to blame for all the dysfunction in their lives. The pandemic has amplified insecurities and struggles that normally accompany adolescence. Reminding trainees, reminding patients that we are whole people at the core can change the perspective about how we take care of people.

Agustín: I think that’s a wonderful and very anthropological frame. Humans are dynamic, active organisms who are always social, through and through. It’s always about relations with ourselves and to others and those patterns and dynamics in our communities. Let’s talk more about training and perceptions. We’ve noted the need to shift from seeing disease as the defining characteristic to seeing the person as the defining characteristic of focus and working with that person toward thinking through health with and for them. But there is another issue, one that has been in medical training and society writ large for a long time. There is much attention, particularly recently, in medical analysis and training about seeing the person as a “race” or as a gender or sex. However, there are important realities associated with race and gender/sex, and not just because of racism and sexism. For example, aspects of bodies related to reproductive biology, which include a very a wide spectrum of physiological patterns and processes, are certainly relevant to health. But those are not the main focus of the current discourse. Rather, it is about rethinking essentialist assumptions about what race is and what it means to reconfigure the discourse and training from the focus on race to one on racism. For example, many in the medical realm still treat race as an essential, biological characteristic, despite the fact that everything about human biology, from genomes to physiology to morphology, illustrates that race is not “from” biology.5 This is evident in initiatives such as race-based corrections6 and the many cases of multiple modes of “racialized” training in medical schools. Am I being overly critical here as an outsider or is this an accurate description?

Lisa: It is accurate. If one looks at how physicians are trained, we are trained to recog- nize patterns and to put signs and symptoms into an algorithm that we’ve learned and memorized. Race became one of those patterns. Myths still exist in medical practice (and training) today, for instance, that African American patients have thicker skin com- pared to other racial groups and as such they are less susceptible to pain. It’s frightening to acknowledge that people continue to internalize such false beliefs. The challenge now is to ask people to consider the reality that “race” is not the risk factor but that racism is the risk factor. We acknowledge that despite phenotypic difference between people, we are genetically very similar and ultimately that race is a social construct, not a biological one. Medical training must adopt this perspective; otherwise, the “health for the whole person” approach is not going to be possible.

I recently read Ibram X. Kendi’s book Stamped (with Jason Reynolds).7 Kendi introduces one of the first published accounts of race or superiority of one group of people over another. In 1415, a biography of the son of King John of Portugal portrayed slavery as mission work, as work of God. The biographer described African people as savage and hypersexual animals that needed taming. At its very basic element, there was a structure of power and dominance of a superior group over an inferior group, based on skin color and place of origin. This pattern of inequity and oppression persists today. Humans are separated by hierarchy of language, of culture, of socioeconomic status and by one group exerting its power over another, and this translates into significant differences in health status and outcomes.

Agustín: And that is how, and why, racism and oppression generate and maintain the concept of race as a “natural,” biological thing. I think this frame is so important as a baseline for understanding. From an anthropological perspective, our understanding of human biology and human genetics, we know that, as you said, race is a social construct, but racism — the discrimination, bias and oppression of individuals because of the social construct they’re categorized as — has real biological, physiological and significant health effects. In one sense, what you said, “Race is not the risk factor, racism is,” it’s absolutely in line with everything we’ve just been describing about health, but it’s also so hard because then one has to say, “Well, where is racism and what is racism in soci- ety?” and connect it to health processes.

We see these patterns of bias against non-White individuals, bias in different ways against different groups, classified and racialized in different ways. It’s interesting because in medical school there is still this conceptualization of humans as having some biological or lineage differentiation that’s either continental (Africa, Europe, Asia) or characterizable by the cat- egories White, Black, Asian, Native American, Latinx. What’s really interesting is that the data are clear — we know this is not the case. Continental groupings are not biological groupings. Black, White, Asian — those are not biological units at any level.8 Yet, this pernicious and malicious belief is maintained.

What do you think the trick is to fix this? I know there’s a whole societal issue here, but what can be done in medical education to take the mostly altruistic, determined, committed individuals who enter medical school and maybe not beat those traits out of them but encourage them, and also change the way they think about race and racism so that they swap causalities and understand it’s the structural processes from systemic and systematic racism that impact racialized groups in different ways?

Lisa: I recommend that whenever you study a disease process and you have categorized race and ethnicity as a risk factor you turn that around and rephrase this as racism as the risk factor. You can also insert other discriminatory “-isms” such as sexism or homopho- bia as contributing factors to the presentation of disease. By changing this language, you reorient the focus, which then informs your approach to evaluation and treatment. You don’t have rewrite whole algorithms of disease, but you will need to consider this social impact as influential. You don’t have to reinvent the wheel, but you must consider what components make up the car. I’ll give an example. I practice obstetrics and there are people who may go into labor before 37 weeks gestational age, which we call preterm labor. One of the risk factors is listed as race and ethnicity. Could it be the racism that the young mother has suffered, compounding on adverse childhood experiences in addition to insufficient access to reliable transportation, financial insecurity and unstable social relationships leading to physical abuse and trauma? Each of these components of her history contributes to a susceptibility to a wide array of pregnancy complications. Everything we know about health and bodies and social lives indicates that the interaction and combination of all of these factors are the root causes of this medical condition and not the color of her skin or other attributes that might be classified as “race.”

Agustín: That’s absolutely right. The question of medical school curricular change is obviously necessary. But there is also a need for perceptual change because young folks are coming into med school after four years of college or university training and still holding these racialized beliefs. So, it’s not just about medical schools, it’s about society at large. One place to really make a difference is basic academic training.

I want to go to an area where you have expertise and an area I’ve been thinking about a lot. Much of the discourse about racism, its relationship to medical training and to understanding health, deals with the classic Black-White context here in the United States. Something that flies more under the radar intellectually and publicly but is very important on the ground for doctors and for a wide number of individuals is what we might call Hispanic, Latinx, “Latinidad” here in the United States and the relationship between the medical establishment and doctors and the perception of Latinx or Latina/o individuals across the board. Can you reflect a little bit on that? I don’t think it has been engaged enough, or sufficiently, in these types of discussions because of the complexity. El mundo Latino is incredibly diverse. It maps across what might be called races. It maps across geographic origin. It maps across —

Lisa: Political affiliations.

Agustín: Yeah, and diverse histories. Yet, my assumption is — and you would know better than I — that in medical training and in the broader medical context, there’s this Hispanic/Latino category that is still deployed as if it were a uniform “race.”

Lisa: Yes. I would say that I experienced this as a medical student. When I identify as Latina, there may be immediate assumptions about my country of origin, my socioeconomic background and life experiences that have followed a defined path. The Latinx term was created approximately 10 years ago in the context of being more inclusive with respect to identification by gender, because in Spanish we have the suffix endings of o and a to differentiate masculine and feminine pronouns. By substituting x for a and o, the intention is to reflect the nonbinary spectrum of gender identity. This term was initially used in academic settings to describe a heterogeneous group of people with Spanish-speaking ancestry. Since then it has become more commonplace outside of academic settings and seems to have replaced the word Hispanic, which was introduced by the U.S. Census Bureau in the 1970s. It may be more politically correct to say Latinx rather than assume a country of origin. Yet not all persons who have ethnic heritage from Spanish-speaking countries will identify with one blanket term. I grew up in the southwest of New Mexico, where we were taught to admire our “Hispanic heritage.” As I became more socially conscious and aware, I identified more as Latina, or Chicana. Our instinct is to compartmentalize people into one category, but even if we might be united by a commonality such as language, linguistic differences abound. In New Mexico, for example, it’s more common to hear Spanglish. My parents grew up speaking both Spanish and English. My grandparents were bilingual. My greatgrandmother was bilingual. The Spanish language unifies groups of varying ethnicities and heritage, but at an elemental level there are important and unique differences.

Agustín: I think that’s so important because around the United States, even what’s categorized as Latinx could be an indigenous individual from Guatemala, or someone who’s an eighth-generation person in the United States from Los Angeles, versus someone from Sonora in northern Mexico whose family migrated in the 1940s or 1950s to be part of the agricultural industry. Then there is the whole Afro-Latino reality from the Caribbean and many places in South America. Yet medically, this is another one of those examples about racism. Because there’s an assumption about a biological “unity” (Hispanic/Latinx), the medical practitioner is going make some assumptions about what the person’s health is and what that person “is.”

Lisa: What I appreciate that’s happening now in medical school and a lot of other fields is recognition of the role of implicit bias. It’s acknowledging that I may have preconceived notions about a person and that I should challenge these thoughts as I continue to interact with them. An important tool for medical students is that recognizing biases and continually improving and optimizing their interactions with others is a dynamic learning process. Here is a patient who happens to have a particular ethnic background that makes them diverse in particular ways but who also has individual fears, individual experiences that bring them to you as a person, as a whole person. We return to our topic of the holistic approach toward the whole person … one has to start from there.

Agustín: This whole concept of thinking about medical training and medical engage- ment and the practice of medicine as a re- conceptualizing of health — we could go back to the future, to the WHO 1948 definition, and combine it with the anthropological recognition that humans are always social. They’re always part of community. Those communities are diverse. Communities and individuals are impacted by the societies in which they live. There are inequities, structures of violence, structure of facilitation and constraint and also the evolutionary histories. What is diversity? What does human biology look like?

The concept of how to successfully be human socially, biologically, psychologically is so dynamic. The anthropologist might say, “Hey look at all this,” to a medical school. Then how do you, given the current constraints of curriculum in medical school, initiate change? What are the changes that are happening now? You said implicit bias, so I assume there’s some training in implicit bias. Training in implicit bias is good, but without an understanding of the structures of systemic racism, how do you figure that out once you get into the world as a doctor?

Lisa: In addition to reorienting racism as the risk factor rather than race and ethnicity, we should also ask ourselves, “How do issues of equity affect the health of the individual?” Which people are disproportionately represented as we consider chronic diseases such as hypertension and type 2 diabetes? Are there groups of people who are more vulnerable if we think about a specific medical condition? How do we consider these topics on a broader scale, beyond disease and health? Who is impacted disproportionately in one’s community? This type of thinking should be reinforced until it becomes a habit.

I went to medical school for four years and completed residency training in three years. I didn’t come out of residency knowing everything, but I knew where to look for the tools to help me answer clinical questions. I had a foundation to guide the workup of medical conditions, even if I had never seen them as a student. We need to move toward also equipping medical students with the skills to be able to recognize, “Ok, my implicit bias exists, and I know where to look to gain insight and assistance in dealing with it.” There are communities of color or other marginalized populations that might be disproportionately affected. We can cultivate the skills to recognize that.

How do we continue to make this a part of our vocation and training to recognize those differences? It’s not about equipping medical students to come out feeling as if they have nothing else to learn. In my work with the American Academy of Family Physicians, our subgroup on health equity is exposed to terms such as cultural competence, cultural proficiency and cultural humility. We’re trying to find one term that acknowledges the importance of being open to uncertainty and inclusivity. We want to prepare medical students with the knowledge and confidence that they will be lifelong students of education.

I learn new things every day in my practice. I began a meditation exercise at the start of the pandemic which has since influenced how I teach medical students, resident trainees and patients alike. I remind students to take a step back and relearn the compassion and altruism they identified as premedical students and also to keep moving forward.

Agustín: What you described there, I would argue, is so central in the tenets of an anthropological engagement of care. The broad notion of the capacity for compassion for humans we know is deep. It’s deep in our evolutionary history, and we know that care and compassion, collaboration, mutual aid form the center of societies, structures of kinship and connection. What you’re describing is something that’s eminently human. In retrospect, we have to ask ourselves why this practice/perspective has not been what’s going on at the very core of medical training. It is, of course, because of the structures of racism, sexism and bias that are ubiquitous in our society and thus also part of the training programs.

Here’s an opportunity. There’s a discourse. Here we are in 2021. A podcast from the prestigious Journal of the American Medical Association stated that no doctors are racist and that systemic racism is not a worthwhile frame for medical discourse. The backlash was substantial, leading to reorganization at JAMA and the AMA and increasing calls by medical professionals and scholars for a reckoning of the ubiquity and impact of medical racism and a restructuring of systems of teaching and practice.9 Also in 2021, the NFL was finally shamed into discontinuing its racist “correction” for cognitive function in its brain injury compensation program.10 The world is talking more, or, let’s say, more people in the world are talking more about these issues. So thinking about what we can do as individual practitioners, anthropologists, doctors, instructors in medical schools and medical students, maybe the next step is to think about dialogues of restructuring. The Journal of the American Medical Association, The New England Journal of Medicine and many other medical journals are publishing statements asserting systemic racism, but at the same time many doctors are rejecting the possibility that medicine is racist and that medical training is maintaining that reality.11

We need dialogues about how to take knowledge from these different areas and provide, as you said, not the answers but the knowledge of where to look, whom to ask and what to do when you don’t know. I think that’s such a powerful frame.

Lisa: Absolutely. What’s even more concerning is the trend of state governments enacting laws to restrict teaching critical race theory in government diversity trainings and classrooms. This recently passed the legislature in Iowa and was signed into effect by the governor.12 A dozen other states have pursued similar legislation. I wonder how this will affect educators’ abilities to present the facts about the impact of systemic racism on health care access and outcomes, in all educational set- tings. This took center stage within our health care system when the former U.S. president issued Executive Order 13950 to “promote unity in the Federal workforce, and to combat offensive and anti-American race and sex stereotyping and scapegoating” by discon- tinuing diversity training that includes sexual orientation and gender identity as well as racial and ethnic diversity. We saw a robust rebuttal from a multitude of clinical departments and organizations to protest this issu- ance, and the brisk response highlighted the potential detrimental impacts on the health and wellness of not only our patients but our colleagues.

Your description also leads me to think of how we view health as a privilege versus a human right. Our technology and advancement enable us to do amazing things, but there is an inherent inequity that leads to different outcomes for the same medical condition in different communities. There are structures in our society where people still don’t have equitable access to health care, even though, fundamentally, I believe it’s a human right.

Agustín: That again, health as a right. Health as a right, psychological, mental health, social health, physical health as — and this framing of rights can be problematic for many, but let us just say it is a logical expectation for all humans to have when they’re born into a society. As you point out, and this is probably a much longer conversation for another place, but it helps us understand structure, this contemporary capitalist mode of health delivery, particularly in the United States — it’s different in other places, but the United States there is an economic cost-benefit structure to the delivery of health care. Everything that we’ve just been talking about — the training, equity, this reconceptualizing health — also has to be done in a frame either that continues this way with the capital- istic structure, the idea that there’s a profit to be made, or maybe a new training, a new context that has to go hand in hand with a larger readjustment suggesting these kinds of profit-based health delivery systems are not compatible with health.

Lisa: Yes.

Agustín: To wrap this up, redefining health, thinking about the reasons why individuals go to med school and then thinking about the life of the physician post med school is such a complicated and difficult reality. Yet the possibility for collaboration among medical training, anthropology, human biology, this broader understanding of society and systems, there’s a need for it more than ever.

Lisa: There is, and I think that we have to be open and continue the dialogue, just like the conversation we’re having now. As a lifelong learner, when you’re acquiring a new skill, you don’t know what you don’t know. When you blur those lines between the fields of anthropology, evolution, how we work as humans in medicine, there are more commonalities than differences. There are more opportunities to collaborate — I think the bounds are limitless — to really change the way we see medical education, to change the way that we perceive what health is, what disease is, and open up the conversation for patients as well to also accept, again, that there are many successful ways to be human.


1. N. Krieger, “Measures of Racism, Sexism, Heterosexism, and Gender Binarism for Health Equity Research: From Structural Injustice to Embodied Harm — An Ecosocial Analysis,” Annual Review of Public Health 41 (2019): 4.1–4.26; R. Nelson, “Methods without Meaning: Moving Beyond Body Counts in Research on Behavior and Health,” in Evaluating Evidence in Biological Anthropology: The Strange and the Familiar, ed. K. Willermet and S. H. Lee (Cambridge: Cambridge University Press, 2019), 86–100; M. Lock, “Re- covering the Body,” Annual Review of Anthropol- ogy 46, no. 1 (2017), 1–14.

2. R. E. Davis-Floyd, “The Technological Model of Birth,” The Journal of American Folklore 100, no. 398 (1987): 479–495.

3. T.David.Constitution.Geneva:WorldHealth Organization, 2021. https://www.who.int/about/ who-we-are/constitution#:~:text=Health%20 is%20a%20state%20of,belief%2C%20economic%20or%20social%20condition.

4. Faye Ginsburg and Rayna Rapp, “Disability/ Anthropology: Rethinking the Parameters of the Overlaps, Disjunctures and Possibilities Human: An Introduction to Supplement 21,” Current Anthropology 61, Suppl. 21 (2020): S4–S15.

5. J. Benn Torres, “Anthropological Per- spectives on Genomic Data, Genetic Ancestry, and Race,” Yearbook of Physical Anthropology (2019):1–13; D. A. Bolnick, “Individual Ancestry Inference and the Reification of Race as a Biological Phenomenon,” in Revisiting Race in a Genomic Age, ed. B. Koenig, S. Lee, and S. Richardson (New Brunswick, NJ: Rutgers University Press, 2008), 70–88; J. L. Graves, “Why the Non- existence of Biological Races Does Not Mean the Nonexistence of Racism,” American Behavioral Scientist 59 (2015): 1474–1495; C. C. Gravlee, “How Race Becomes Biology: Embodiment of Social Inequality,” American Journal of Physical Anthropology 139 (2009): 47–57; K. L. Hunley, G. S. Cabana, and J. C. Long, “The Apportionment of Human Diversity Revisited,” American Journal of Physical Anthropology 160 (2016): 561–569; J. Marks, “Ten Facts about Human Variation,” in Human Evolutionary Biology, ed. M. Muehlenbein (New York: Cambridge University Press, 2010); D. Roberts, Fatal Invention: How Science, Politics, and Big Business Re-create Race in the Twenty- First Century (New York: The New Press, 2011); A. Saini, Superior: The Return of Race Science (Boston: Beacon Press, 2019); R. W. Sussman, The Myth of Race: The Troubling Persistence of an Unscientific Idea (Cambridge, MA: Harvard University Press, 2016).

6. Dorothy E. Roberts, “Abolish Race Correction,” The Lancet 397, no 10268 (2021): 17–18; N. D. Eneanya, W. Yang, and P. P. Reese, “Reconsidering the Consequences of Using Race to Estimate Kidney Function,” JAMA 322, no. 2 (2019): 113–114; V. Grubbs, “Precision in GFR Reporting: Let’s Stop Playing the Race Card,” Clinical Journal of the American Society of Nephrology 15, no. 8 (2020): 1201–1202.

7. Jason Reynolds and Ibrahim X. Kendi (2020) Stamped: Racism, Antiracism, and You: A Remix of the National Book Award-winning Stamped from the Beginning (New York: Little, Brown Books for Young Readers, 2020); Ibrahim X. Kendi, Stamped from the Beginning: The Definitive History of Racist Ideas in America (New York: Bold Type Books, 2017).

8. A. Fuentes, R.R. Ackermann, S. Athreya, et al. AAPA Statement on Race and Racism. Herndon: American Association of Biological Anthropologists, 2019. https://physanth.org/about/ position-statements/aapa-statement-race-and-rac- ism-2019/.

9. C. C. Gravlee. How Whiteness Works: JAMA and the Refusals of White Supremacy. Somatosphere, 2021. http://somatosphere.net/2021/how- whiteness-works.html/ See also https://jamanet- work.com/journals/jama/pages/audio-18587774 and https://www.forbes.com/sites/brucelee/2021/ 03/07/jama-posts-podcast-on-structural-racism- here-is-the-backlash/?sh=2a68c3d86a56.

10. N.F.L. Concussion Settlement Will Drop Race-Based Assessment for Payouts https://www.nytimes.com/2021/06/02/sports/football/nfl- concussion-settlement-race.html

11. Christina Amutah, Kaliya Greenridge, Adoja Mante, Michelle Munyikwa, Surya L. Sanjina, Eve Higginbotham, David S. Jones, Risa Lavizzo- Mourey, Dorothy Roberts, Jennifer Tsai, and Java Avsola. “Misrepresenting Race — The Role of Medical Schools in Propagating Physician Bias,” New England Journal of Medicine 384 (2021): 872–878; Zinzi D. Bailey, Justin M. Feldman, and Mary T. Bassett. “How Structural Racism Works — Racist Policies as a Root Cause of U.S. Racial Health Inequities,” New England Journal of Medicine 384 (2020): 768–773; M. A. Fair and S. B. Johnson, “Addressing Racial Inequities in Medicine,” Science 372, no. 6540 (2021): 348–349.

12. IanRichardson.“Criticalracetheory:What is it and how does it relate to Iowa’s diversity training bill?” Des Moines Register (Des Moines, IA), June 1, 2021. https://www.desmoines- register.com/story/news/politics/2021/06/01/ what-critical-race-theory-crt-iowa-diversity- training-bill-schools-teaching-definition-educa- tion/7488876002/.


Suggestions for Further Reading

Bailey Zinzi D.; Feldman, Justin M.; and Bassett, Mary T. “How Structural Racism Works — Racist Policies as a Root Cause of U.S. Racial Health Inequities.” New England Journal of Medicine 384 (2021): 768–773.

Fair, M. A., and S. B. Johnson. “Addressing Racial Inequities in Medicine.” Science 372, no. 6540 (2021): 348–349.

Gravlee, C. C. “How Whiteness Works: JAMA and the Refusals of White Supremacy.” 2021. http:// somatosphere.net/2021/how-whiteness-works. html/.

Krieger, N. “Measures of Racism, Sexism, Hetero- sexism, and Gender Binarism for Health Equity Research: From Structural Injustice to Embodied Harm — An Ecosocial Analysis.” Annual Review of Public Health 41 (2019): 4.1–4.26.

Lock, M. “Recovering the Body.” Annual Review of Anthropology 46, no. 1 (2017): 1–14.

Roberts, D. E. “Abolish Race Correction.” The Lan- cet 397, no. 10268 (2021): 17–18.


Agustín Fuentes trained in zoology and anthropology and is professor of anthropology at Princeton University. His current explorations include the roles of creativity and belief in human evolution, multispecies anthropology, evolutionary theory and the structures of race, racism and health. Fuentes’ books include Race, Monogamy, and Other Lies They Told You: Busting Myths about Human Nature (University of California Press, 2015), Con- versations on Human Nature(s) (with Aku Visala; Routledge, 2015), The Creative Spark: how imagination made humans exceptional (Dutton 2017) and Why We Believe: Evolution and the Human Way of Being (Yale University Press, 2019).

Eleanor Lisa Lavadie-Gómez is clinical assistant professor in the Department of Family Medicine at the University of Iowa Healthcare and the Roy J. and Lucille A. Carver College of Medicine, in Iowa City. She provides outpatient clinical care and ob- stetric care and has special interests in medical education, caring for the Latinx community and care for underserved populations. She is an active member of the American Academy of Family Phsicians and a commission member for the American Academy of Family Physicians Commission of Health of the Public and Science.

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