AJPH PUBLIC HEALTH OF CONSEQUENCE

Living and Dying at the Crossroads:Racism, Embodiment, andWhyTheoryIs Essential for a Public Health ofConsequence

See also Galea and Vaughan, p. 783.

Why is theory relevant toa public health of consequence?Because theory stands at thecrossroads of imagination, ob-servation, metaphor, insight, andaction.1 Theory, literally inwardsight (per its original ancientGreek etymology1) is what en-ables researchers, practitioners,and activists alike first to “see” thedots before we can even “con-nect” them, let alone speculateabout or address potential causalprocesses that create the observedconnections and patterns. Themost fervid debates in publichealth (and other sciences) arerarely about “the facts” but rathertheir explanation. For example,none would dispute, 100 yearsago or today, that the on-averagelife expectancy is shorter amongpeople in the United Statesclassified as Black versus White(quibbles over the margins oferror affecting these estimatesnotwithstanding); by contrast,controversies have raged, thenand now, over whether thispattern reflects biological orcultural inferiority versus socialinjustice.1

Theory is vital to adducingcause and to conceptualizing andenvisioning structures and sys-tems that shape health but which

lie outside of what a physical scalecan measure or an unaided eyecan see.1,2 Consider the theo-retical proposition that the pri-mary drivers of population healthand health inequities are to befound within our body politic,notwithin our bodies.1Of coursemeasurable aspects of biology areinvolved—but it is hypothesesspurred by theory that allow fordiscriminating between expla-nations open to understandingthese biological parameters asbiological expressions of societalconditions, versus as innate char-acteristics that govern our fate.

Theory invites us to thinkwith metaphors, to spark newconnections in our pattern-seeking minds.1 In the case ofwork on racism and health, forexample, I have found that theconceit of “crossroads,” crossedwith theory, can be consequen-tial in at least five ways.2

First, crossroads reminds us tobe interdisciplinary or trans-disciplinary. While my worklinking racial injustice to pop-ulation health is grounded inepidemiology, that is, the study ofdistributions and determinants ofhealth and disease in populations,I necessarily draw on otherdisciplines and their theories,

including history, biology, soci-ology, psychology, statistics, andphilosophy of science, to namebut a few.1,2

Second, crossroads, by defini-tion, imply and create bound-aries, and my work, like all workin the population sciences, con-fronts thorny questions of con-ceptual, social, and spatialboundaries, such as defining whoand what makes “populations”(say, in relation to race/ethnicity,social class, gender, sexuality, ornationality), and also who andwhatmakes a “neighborhood” or“nation.”1–3

Third, crossroads involvejunctures and journeys. In-terwoven and interacting socie-tal, biological, and ecologicalsystems are central to how Iconceptualize “embodiment,”one of the core constructs of theecosocial theory of disease dis-tribution I have been developingsince 1994.1 By embodiment,I mean how people literallyembody, biologically, the mul-tilevel dynamic and

coconstituted societal and eco-logic context within which welive, work, love, play, fight, ail,and die, thereby creating pop-ulation patterns of health, disease,and well-being within and acrosshistorical generations. Of note,the main metaphor of ecosocialtheory evokes crossroads, becauseit interleaves two fractal struc-tures that span from macro tomicro: the ever-evolving tree, orrather, bush of life, and the his-torically forged scaffolding ofsociety that different societalgroups daily seek to reinforce oralter, via strengthening or chal-lenging the status quo. Imagine,for example, a vine weaving itsway in and out across the surfaceof a chain-link fence, and see thatself-same structure repeated, atmyriad scales and levels, from theglobal to the subcellular. Theplethora of crossroads should beapparent—as should how societalconditions shape options for or-ganisms and species to thrive orperish, as the global emergency ofclimate change makes all tooclear.

Fourth, crossroads, by defini-tion, are branched structures,a form critical for understandingprobabilities, and our work inpublic health grapples with theinterplay of structure and chanceas they jointly shape individualrisk and population rates of dis-ease.3 It is no accident that

ABOUT THE AUTHORNancy Krieger is Professor of Social Epidemiology and American Cancer Society ClinicalResearch Professor, Department of Social and Behavioral Sciences, Harvard T.H. ChanSchool of Public Health, Boston, MA.

Correspondence should be sent to Nancy Krieger, PhD, Professor of Social Epidemiology,Department of Social and Behavioral Sciences, Kresge 717,Harvard T.H.Chan School of PublicHealth, 677 Huntington Ave, Boston, MA 02115 (e-mail: nkrieger@hsph.harvard.edu).Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.

This article was accepted January 27, 2016.doi: 10.2105/AJPH.2016.303100

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a predilection for playing withchance and contingency is a keyfeature of the myriad gods,goddesses, and mythical figuresassociated with or worshipped atthe crossroads, whether Hermesand Hecate in ancient Greece,Eshu among the Yoruba inNigeria and his counterpartsworldwide among the slavery-driven African diaspora, Loki inthe Nordic realms, or Coyote orRaven among different NorthAmerican Indigenous peoples.4

Neither fate nor luck has thelastword; theory gives us thevisionand responsibility to create equi-table societies that proportionatelyincrease the odds, in relation toinjustice and need, for all to livehealthy and dignified lives.

Fifth and finally, the work ofpublic health is itself located atthe crossroads of science and so-ciety. I mean this in two ways.The first refers to the socialproduction of science and thesocial responsibilities of scientists;notably, the field-shaking 1931conference compendium thatintroduced these ideas to thefield of history of science andtechnology studies was called“Science at the Crossroads.”5

The second refers to how societalchange and the work of publichealth alters the very phenomenawe study and the scientificproblems we need to solve. Sucha reflexive and consequentialunderstanding of our theories andpractice infuses Winslow’s vi-sionary 1926 article “PublicHealth at the Crossroads,”6 ini-tially given as a presidential ora-tion for the American PublicHealth Association, and in whichhe broke new ground by raisingthe public health, medical, andsocial implications of the US andEuropean decline in infectiousdisease mortality rates and thecorresponding growing burdensof chronic noncommunicablesomatic and mental ailments.

In summary, a theoreticalvantage is crucial to seeing andappraising evidence. In the case ofracism and health, it is what al-lows us in public health to pro-pose that police killings andpolice deaths be counted aspublic health data, rather thansolely as criminal justice data, so asto increase accountability and thelikelihood of prevention.7 It iswhat reminds us that Jim Crow iswith us still, as embodied history,since every person born in theUnited States before 1965, that is,aged 50 years and older, was bornwhen Jim Crow was the law ofthe land in 21 US states, withbirth conditions affecting notonly their adult health status andmortality but their children’shealth as well.2 It is what fostersresearch on associations betweenimplicit and explicit measures ofexposure to racial discrimination,racialized economic segregation,and adverse health status2—andmakes clear there is nothing“distal” about structural dis-crimination because it is in-timately encountered andembodied, day in and day out.1–3

Ultimately, to challenge thestill dominant ahistorical anddecontextualized biomedical andlifestyle theories of disease dis-tribution, which reduce causes ofdisease to individuals’ geneticconstitution and “personaltastes”1 and deem it “political” toaddress racism and health, as ifignoring this issue were notequally political, we need theory.Why? Because it affords us al-ternative frameworks to analyze,in context, population health andhealth inequities as embodiedhistory, revealing theworkings ofstructured chance3 in our jointlybiophysical and social world—acrossroads if ever there were one.

All of us, all people, are born,live, and die at these crossroads.To alter the odds, for good or forill, of who ails and dies of what

conditions at what age requiresconcerted conscious action, in-formed by theory. Informing theconsequences of these actions arethe theories and values priori-tized: think only of the cleanwater fights of the mid-19thcentury CE that galvanized themodern public health move-ment,1 or the clean water fightnow under way in Flint,Michigan, where governmentdepravity in cost-cutting—led byelected and appointed officials,and simultaneously aided andfought by differing factionswithin state public health andenvironmental agencies—resulted in contaminating thecity’s water, with its largely Blackand low-income residents nowrelying on bottled water andfearing for the long-term con-sequences of lead poisoning oftheir children.8 A public health ofconsequence knows that re-actionary politics and policies willmagnify health inequities, pro-gressive politics and policies canhelp eliminate them. These arethe crossroads at which wepresently stand.

Nancy Krieger, PhD

ACKNOWLEDGMENTSPreparation of this article was in partsupportedby theAmericanCancerSocietyClinical Research Professor Award.

REFERENCES1. Krieger N. Epidemiology and the People’sHealth: Theory and Context. New York,NY: Oxford University Press; 2011.

2. Krieger N. Discrimination and healthinequities. In: Berkman LF, Kawachi I,Glymour M (eds). Social Epidemiology. 2nded. New York, NY: Oxford UniversityPress; 2014.

3. Krieger N. Who and what is a “pop-ulation?’ Historical debates, currentcontroversies, and implications for un-derstanding “population health” andrectifying health inequities. Milbank Q.2012;90:634–681.

4. Hyde L. Trickster Makes This World:Mischief, Myth and Art. 2nd ed. Edinburgh,Scotland: Canongate; 2008.

5. Science at the Crossroads: Papers Pre-sented to the International Congress of theHistory of Science and technology Held inLondon from June 29th to July 3rd, 1931 bythe delegates of the U.S.S.R, with a newforeword by Joseph Needham, and a newintroduction by P.G. Werskey, 2nd ed.London, UK: F. Cass; 1971.

6. Winslow C-EA. Public health at thecrossroads. Am J Public Health. 1926;16:1075–1085.

7. Krieger N, Chen JT, Waterman PD,Kiang MV, Feldman J. Police killings andpolice deaths are public health data and canbe counted. PLoS Med. 12(12):e1001915.

8. Bosman J, DaveyM, SmithM. As waterproblems grew, officials belittled com-plaints fromFlint.NewYork Times, January20, 2016. Available at: http://www.nytimes.com/2016/01/21/us/flint-michigan-lead-water-crisis.html.Accessed January 26, 2016.

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