"Bodies Count," and Body Counts: Social Epidemiology and Embodying Inequality

Abstract

Bodies count. In epidemiology, this statement would appear to be a core proposition, for it is by counting people—in varying states of health, disease, and disability, the alive and the dead—that we derive our estimates of population rates and risks of morbidity and mortality. But bodies count for more than this, for, in their manifest form—in height, weight, physique, and overall appearance (including posture and disfigurement)—they provide vivid evidence of how we literally embody the world in which we live, thereby producing population patterns of health, disease, disability, and death (1–5). Readily identifiable to the naked eye, these aspects of our being not only are predictive of future health outcomes but also tell of our conjoined social and biologic origins and trajectories. In this paper, we argue that the field of social epidemiology has much to gain by considering the construct and reality of “embodiment,” and hence the causes and consequences of bodily constitution (1–5). At issue is how social influences become literally embodied into physio-anatomic characteristics that influence health and become expressed in societal disparities in health. In our view, a concern with differences in macroscopic physiology—or what Laurell has tellingly termed “class physiognomies” (6, p. 1184)—usefully turns attention toward topics often overlooked by much contemporary social epidemiology in the United States and Europe, with its focus on neuroendocrine and behavioral responses to psychosocial stressors, posited both to be directly pathogenic and to increase susceptibility to other exogenous exposures (7–12). While research mending the “mind/body” rift long characterizing biomedicine is important, it is equally critical to recognize that, in addition to being mindful, bodies also are literally corporeal. Asking the question as to whether bodily being can itself affect health in no way discounts that 1) people’s behavioral, emotional, and cognitive responses to adverse (and beneficial) circumstances may influence somatic health (in ways that vary according to disease outcome); 2) psychosocial adversity impairs the quality of people’s lives, whether or not it harms somatic health; and 3) psychosocial stressors are socially patterned (with some groups being subject to unique stressors, e.g., racial discrimination) (5, 10, 12, 13). Rather, by emphasizing the literal nature of embodiment and refocusing on key aspects of what bodies do, we can potentially generate new insight into the ways societal conditions shape expression of biologic traits, population distributions of disease, and social inequalities in health. Importantly, a concern with bodily characteristics is not new to epidemiology but rather dates back to the field’s modern origins in the early 19th century (14–16). In the 1820s, for example, Louis René Villermé (1782–1863) conducted pathbreaking research demonstrating that wealth was inversely associated with both risk of mortality in Parisian neighborhoods and short stature, illness, and deformities among young military conscripts (table 1) (14, 17, 18). He further observed that “qu’en generale, ches lez personnes d’une petit stature ... les membres inferieurs sont plus courts que chez les personnes d’une grande taille” (“in general, among persons of small stature ... the lower limbs are much shorter than those of persons of great height”) (17, p. 351). The implication, explicitly recognized by Villermé, was that body size, body proportions, and longevity, far from being fixed, bore the imprint of economic conditions and could be affected by government policies (14, 17, 18). Recognition of links between bodily constitution and the body politic likewise gained attention in England in the 1830s and 1840s, during the throes of the Industrial Revolution (15, 16, 19, 20). In one of the era’s classic texts, The Condition of the Working Class in England in 1844 (21), Friedrich Engels (1820–1895) vividly described the bodily impact of the workers’ abysmal working conditions, food, housing, and inadequate medical care, arguing: All of these adverse factors combine to undermine the health of the workers. Very few strong, well-built, healthy people are to be found among them … They are for the most part, weak, thin and pale. … Their weakened bodies are in no condition to withstand illness and whenever infection is abroad they fall victims to it. Consequently they age prematurely and die young. This is proved by the available statistics of death rates (21, pp. 118–119). Concerned with the lifelong consequences of inequity, he concisely stated, “Common observation shows how the sufferings of childhood are indelibly stamped on the adults” (21, p. 115). He likewise recounted how the factory hands he met in Manchester were worn out at age 40 and looked 10 years older, while the prosperous classes preserved their appearance well—if they could restrain their desire to drink excessively. Anticipating the conclusions of