Embodying history and understanding health inequities: On emergent phenotypes and the four histories of the breast cancer estrogen receptor – evolutionary, pathological, individual, and societal

Understanding the causes of health inequities matters not only for preventing unjust ailments, injuries, and deaths that need not have occurred: it also poses deep conceptual challenges to dominant approaches to analyzing etiology. Standard practice is to compare the present (or absent) biological characteristics – and, increasingly, genomic profile – of those affected versus not. Might, however, a broader, more dynamic framing of the relevant biology be warranted, one that incorporates the multiple histories, from evolutionary to cellular to individual to societal, that together shape individual and population risks of morbidity and mortality?

The case of the breast cancer estrogen receptor offers a powerful prism through which to consider the starkly divergent clinical and public health implications of these two contrary conceptualizations of biology and disease origins. In this presentation I critically examine what I term the four histories of the breast cancer estrogen receptor – evolutionary, pathological, individual, and societal. I argue that these histories are not only are at play (concurrently, not sequentially) in every case and every population rate of disease but also together reveal that history matters – deeply, at multiple levels and timescales – to claims about disease etiology and causes of health inequities. To see disease and its biomarkers, along with changing magnitudes of health inequities, as embodied history, that is, emergent phenotypes, not intrinsic biology, offers a radically different, inclusive, and promising perspective for public health and clinical medicine alike.