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- Herausgeber: John Wiley & Sons
- Kategorie: Wissenschaft und neue Technologien
- Serie: Critical Introductions to Geography
- Sprache: Englisch
Health Geographies: A Critical Introduction explores health and biomedical topics from a range of critical geographic perspectives. Building on the field’s past engagement with social theory it extends the focus of health geography into new areas of enquiry.
- Introduces key topics in health geography through clear and engaging examples and case studies drawn from around the world
- Incorporates multi-disciplinary perspectives and approaches applied in the field of health geography
- Identifies both health and biomedical issues as a central area of concern for critically oriented health geographers
- Features material that is alert to questions of global scale and difference, and sensitive to the political and economic as well sociocultural aspects of health
- Provides extensive pedagogic materials within the text and guidance for further study
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Veröffentlichungsjahr: 2017
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Table of Contents
Cover
Title Page
List of Figures
List of Tables
List of Boxes
Notes on Contributors
Foreword
Acknowledgements
Chapter 1: Introduction
Introduction
A Critical Introduction to Health Geography?
Applying a Critical Perspective to Our World
A ‘Road Map’ to
Health Geographies: A Critical Introduction
References
Part I: Body, Health and Disease
Chapter 2: The Body in Health Geography
Introduction
Disembodied Geographies
Representational Geographies: Pathologising Bodies and Spaces
From Representation and Governance to Materiality and Embodiment
Conclusion: More‐than‐human Bodies
Questions for Review
Suggested Reading
References
Chapter 3: Health and Place
Introduction
Medical Geography: Place as Location
Health Geography
Conclusion
Questions for Review
Suggested Reading
References
Part II: Changing Spaces of (Health) Care
Chapter 4: Landscapes of Wellbeing
Introduction
Wellbeing: Its Emergence and Development
Therapeutic Landscapes: Definitions and Beginnings
Conclusion
Questions for Review
Suggested Reading
References
Chapter 5: (Re)Locating, Reforming and Providing Health Care
Introduction
Locating Health Care
Reforming Health Care
Changing Places: Institutions and Neoliberal Thinking
Place and the Evidence‐Based Agenda
Conclusion
Questions for Review
Suggested Reading
References
Chapter 6: Spaces of Care
Introduction
Care: Mapping the Boundaries of an Ideological Term
Tracing the Everyday Spaces of Care
Eroding Places of Care in a Post‐welfare State
An End to Care?
Conclusion
Questions for Review
Suggested Reading
References
Chapter 7: Post‐Asylum Geographies
Introduction
Asylum Geographies
A Failed Ideal and the Grassroots of Reform
Post‐Asylum Geographies
Placing Contemporary Mental Health
Conclusion
Questions for Review
Suggested Reading
References
Part III: Producing Health
Chapter 8: Ecological Approaches to Public Health
Introduction
Placing the Geography of Health Inequalities
Thinking Critically about Neighbourhood and Contextual Effects on Health
Conclusion
Questions for Review
Suggested Reading
References
Chapter 9: Capturing Complexity
Introduction
Tensions in Ecological Health Research
Towards Realistic Complexity in Ecological Health Research
Implications of Complexity for Health Geography Research
Conclusion
Questions for Review
Suggested Reading
References
Chapter 10: Interventions for Population Health
Introduction
Improving Health or Reducing Inequalities?
Environmental Interventions and Population Health
‘Natural Experiments’: Generating Better Quality Evidence
Conclusion
Questions for Review
Suggested Reading
References
Part IV: Emerging Geographies of Health and Biomedicine
Chapter 11: Epidemics and Biosecurity
Introduction
What Causes Epidemic Disease?
Disease Ecology
Tackling Epidemics
Governing Epidemics: Biopolitics, Securitisation and Global Threat
Conclusion
Questions for Review
Suggested Reading
References
Chapter 12: Pharmaceuticalisation and Medical Research
Introduction
Bioprospecting: Sourcing New Active Compounds
Clinical Trials
Constituting Pharmaceutical Markets
Addressing the ‘Global Drug Gap’
Conclusion
Questions for Review
Suggested Reading
References
Chapter 13: Health and Medical Tourism
Introduction
Early Forms of Health and Medical Tourism
Defining Medical Tourism
Who are Medical Tourists?
Where do they Travel and in what Numbers?
What are the Impacts of Medical Tourism?
Medical Tourism and Health Geography
Conclusion
Questions for Review
Suggested Reading
References
Chapter 14: Global Health Geographies
Introduction
From International Dialogue to Overseas Intervention
Emerging Global Biopolitics
Bureaucratising Global Health
The Economisation of Global Health
Critical Geographies of Global Health
Conclusion
Questions for Review
Suggested Reading
References
Index
End User License Agreement
List of Tables
Chapter 08
Table 8.1 The analysis grid for environments leading to obesity (ANGELO) framework.
Chapter 10
Table 10.1 Standardised mortality rates for men aged 15–64.
Chapter 11
Table 11.1 Comparison of history’s worst epidemics by number of deaths. Data taken from
National Geographic
(2014) and WHO (http://apps.who.int).
Table 11.2 Several recent diseases mapped against Fraser’s four key criteria for a major epidemic outbreak. Data taken from Young (2015).
Table 11.3 Average life expectancy by social status and UK district according to Chadwick’s 1842 report.
Chapter 12
Table 12.1 Key phases of the drug development process.
Chapter 13
Table 13.1 A typology of medical tourists.
Table 13.2 Costs (US$) of a series of medical procedures in the United States, Germany and India in 2012. Data taken from http://www.washingtonpost.com/wp‐srv/special/business/high‐cost‐of‐medical‐procedures‐in‐the‐us/, viewed 15 April 2016.
Chapter 14
Table 14.1 Status of the WHO malaria eradication programme, September 1968.
List of Illustrations
Chapter 01
Figure 1.1 Male life expectancy on the Jubilee Line, London.
Chapter 02
Figure 2.1 ‘A hard job,’ the front cover from the
San Francisco Illustrated Wasp
published in August, 1878.
Chapter 06
Figure 6.1 The ‘left behind’ generation from global care chains, as evidenced in Albania.
Figure 6.2 ‘Supportive currents’ within US cities.
Figure 6.3 A disappearing landscape of day care?
Figure 6.4 Time to CARE from a rooftop in Detroit, MI.
Chapter 07
Figure 7.1 St. Loman’s Hospital (formerly Mullingar District Lunatic Asylum), Mullingar, Ireland (built 1847).
Figure 7.2 Kalamazoo Psychiatric Hospital, Michigan.
Figure 7.3 Apartments at Knowle former asylum.
Figure 7.4 Tokani derelict asylum, New Zealand.
Chapter 08
Figure 8.1 Conceptual model of the possible neighbourhood pathways for cardiovascular disease risk.
Chapter 09
Figure 9.1 Extract of Foresight Obesity System Map.
Figure 9.2 Simple, complicated and complex systems models illustrated.
Chapter 11
Figure 11.1 Catch it, Bin it, Kill it – respiratory and hand hygiene campaign in the United Kingdom (2008–2009).
Chapter 12
Figure 12.1 Top 10 biotech and pharmaceutical companies worldwide 2013, based on market value (in billion US dollars).
Chapter 13
Figure 13.1 Exhibit from “Mapping the market for medical travel”, May 2008, McKinsey Quarterly, www.mckinsey.com.
Guide
Cover
Table of Contents
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Critical Introductions to Geography
Critical Introductions to Geography is a series of textbooks for undergraduate courses covering the key geographical sub disciplines and providing broad and introductory treatment with a critical edge. They are designed for the North American and international market and take a lively and engaging approach with a distinct geographical voice that distinguishes them from more traditional and out‐dated texts.
Prospective authors interested in the series should contact the series editor: John Paul Jones III School of Geography and Development University of Arizona [email protected]
Published
Cultural GeographyDon Mitchell
Geographies of GlobalizationAndrew Herod
Geographies of Media and CommunicationPaul C. Adams
Social GeographyVincent J. Del Casino Jr
MappingJeremy W. Crampton
Research Methods in GeographyBasil Gomez and John Paul Jones III
Political Ecology, Second EditionPaul Robbins
Geographic ThoughtTim Cresswell
Environment and Society, Second EditionPaul Robbins, Sarah Moore and John Hintz
Urban GeographyAndrew E.G. Jonas, Eugene McCann, and Mary Thomas
Health Geographies: A Critical IntroductionBy The right of Tim Brown, Gavin J. Andrews, Steven Cummins, Beth Greenhough, Daniel Lewis, and Andrew Power
Health Geographies
A Critical Introduction
Tim BrownGavin J. AndrewsSteven CumminsBeth GreenhoughDaniel LewisAndrew Power
This edition first published 2018© 2018 John Wiley & Sons Ltd
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.
The right of Tim Brown, Gavin J. Andrews, Steven Cummins, Beth Greenhough, Daniel Lewis, and Andrew Power to be identified as the authors of this work has been asserted in accordance with law.
Registered OfficesJohn Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USAJohn Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
Editorial Office9600 Garsington Road, Oxford, OX4 2DQ, UK
For details of our global editorial offices, customer services, and more information about Wiley products visit us at www.wiley.com.
Wiley also publishes its books in a variety of electronic formats and by print‐on‐demand. Some content that appears in standard print versions of this book may not be available in other formats.
Limit of Liability/Disclaimer of WarrantyWhile the publisher and authors have used their best efforts in preparing this book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. It is sold on the understanding that the publisher is not engaged in rendering professional services and neither the publisher nor the author shall be liable for damages arising herefrom. If professional advice or other expert assistance is required, the services of a competent professional should be sought.
Library of Congress Cataloging‐in‐Publication Data
Names: Brown, Tim, 1968– author. | Andrews, Gavin J., 1970– author. | Cummins, Steven, (Geographer), author. | Greenhough, Beth, author. | Lewis, Daniel (Geographer), author. | Power, Andrew, 1979– author.Title: Health geographies : a critical introduction / Tim Brown, Gavin J. Andrews, Steven Cummins, Beth Greenhough, Daniel Lewis, Andrew Power.Description: Chichester, UK ; Hoboken, NJ : John Wiley & Sons, 2018. | Includes bibliographical references and index.Identifiers: LCCN 2016057491 (print) | LCCN 2017009192 (ebook) | ISBN 9781118739037 (cloth) | ISBN 9781118739020 (pbk.) | ISBN 9781118738993 (Adobe PDF) | ISBN 9781118739013 (ePub)Subjects: LCSH: Medical geography.Classification: LCC RA792 .A53 2017 (print) | LCC RA792 (ebook) | DDC 614.4/2–dc23LC record available at https://lccn.loc.gov/2016057491
Cover Image: © JOEL SAGET/GettyimagesCover Design: Wiley
List of Figures
1.1
Male life expectancy on the Jubilee Line, London.
2.1
‘A hard job,’ the front cover from the
San Francisco Illustrated Wasp
published in August, 1878.
6.1
The ‘left behind’ generation from global care chains, as evidenced in Albania.
6.2
‘Supportive currents’ within US cities.
6.3
A disappearing landscape of day care?
6.4
Time to CARE from a rooftop in Detroit, MI.
7.1
St. Loman’s Hospital (formerly Mullingar District Lunatic Asylum), Mullingar, Ireland (built 1847).
7.2
Kalamazoo Psychiatric Hospital, Michigan.
7.3
Apartments at Knowle former asylum.
7.4
Tokani derelict asylum, New Zealand.
8.1
Conceptual model of the possible neighbourhood pathways for cardiovascular disease risk.
9.1
Extract of Foresight Obesity System Map.
9.2
Simple, complicated and complex systems models illustrated.
11.1
Catch it, Bin it, Kill it – respiratory and hand hygiene campaign in the United Kingdom (2008–2009).
12.1
Top 10 biotech and pharmaceutical companies worldwide 2013, based on market value.
13.1
Exhibit from “Mapping the market for medical travel”.
List of Tables
8.1
The analysis grid for environments leading to obesity (ANGELO) framework.
10.1
Standardised mortality rates for men aged 15–64.
11.1
Comparison of history’s worst epidemics by number of deaths.
11.2
Several recent diseases mapped against Fraser’s four key criteria for a major epidemic outbreak.
11.3
Average life expectancy by social status and UK district according to Chadwick’s 1842 report.
12.1
Key phases of the drug development process.
13.1
A typology of medical tourists.
13.2
Costs (US$) of a series of medical procedures in the United States, Germany and India in 2012.
14.1
Status of the WHO malaria eradication programme, September 1968.
List of Boxes
2.1
Key Concepts: Disembodied Geographies
2.2
Key Thinkers: Sander Gilman
2.3
Key Themes: Embodiment and Disability Geographies
3.1
Key Concepts: Understandings and Attributes of Place
3.2
Key Thinkers: Robin Kearns
4.1
Key Themes: Types of Wellbeing
5.1
Key Themes: Health Care Restructuring
6.1
Key Concepts: Shadow State
6.2
Key Thinkers: Julia Twigg
6.3
Key Themes: The ‘Big Society’ in the United Kingdom
7.1
Key Thinkers: Chris Philo
7.2
Key Concepts: Total Institution
8.1
Key Concepts: Contextual Explanations for Health Inequalities
8.2
Key Themes: Place Effects on Health
9.1
Key Themes: The ‘Glasgow Effect’
9.2
Key Thinkers: Nancy Krieger
10.1
Key Concepts: Area‐based Interventions
10.2
Key Themes: The Pennsylvania Fresh Food Financing Initiative
11.1
Key Concepts: Miasma and Germ Theories
11.2
Key Thinkers: Michel Foucault and Biopower
12.1
Key Themes: The Drug Development Process
12.2
Key Themes: Creating a Pharmaceutical Market
12.3
Key Themes: India’s Clinical Trial and Patent Regulations
13.1
Key Themes: Indian Hill Stations
13.2
Key Themes: Organ Trafficking and the Positive Side of the Organ Trade?
14.1
Key Themes: Tropical Medicine
14.2
Key Concepts: Structural Adjustment Programmes and Global Health
Notes on Contributors
Tim Brown is Senior Lecturer in Human Geography at Queen Mary University of London. His research explores the critical geographies of public health and more recently global health. He is widely published in these areas in leading geographical and interdisciplinary health journals and is the author/editor of several books, including A Companion to Health and Medical Geography (Wiley‐Blackwell 2010) and Bodies Across Borders (Ashgate 2015).
Gavin J. Andrews is a full Professor and a health geographer based at McMaster University in Canada. His wide‐ranging empirical interests include ageing, holistic medicine, health care work, sports and fitness cultures, health histories of places and popular music. Much of his work is positional and considers the development, state‐of‐the‐art and future of health geography. In terms of theoretical approaches, in recent years he has developed an interest in non‐representational theory and its potential to animate the energies and movements in the ‘taking place’ of health and health care.
Steven Cummins is Professor of Population Health and Director of the Healthy Environments Research Programme at the London School of Hygiene & Tropical Medicine, UK. He is a geographer with training in epidemiology and public health and earned his PhD from the MRC Social & Public Health Sciences Unit, University of Glasgow. He has published extensively on how the urban environment affects health in a range of disciplines including geography, epidemiology, urban studies and health policy.
Beth Greenhough is Associate Professor of Human Geography and Fellow of Keble College, University of Oxford. Her research explores the social and cultural dimensions of health and biomedical research, and has been funded by the AHRC, ESRC, Brocher Foundation and the Wellcome Trust. She has published widely in leading geography and interdisciplinary journals and is co‐editor of Bodies Across Borders (Ashgate 2015).
Daniel Lewis is a Research Fellow at the London School of Hygiene & Tropical Medicine, UK. He has a BA in Geography from LSE, and an MSc in Geographic Information Science and PhD in Geography from UCL. Daniel is a health geographer who is interested in deepening our understanding of the social and spatial determinants of health and health inequalities, and the complex relationships linking individuals and their environments.
Andrew Power is Associate Professor in Geography at University of Southampton. His research examines issues relating to disability, welfare, care and community voluntarism, and has been funded by the AHRC, ESRC and British Society of Gerontology. He has published extensively in leading geographical and disability studies’ journals and is the author/contributor of several books, including Landscapes of Care (Ashgate 2010) and Active Citizenship and Disability (Cambridge University Press 2013).
Foreword
New texts in any area sometimes struggle. We might expect this to be the case in health geography which is well served by two introductory texts and a comprehensive edited handbook summarising recent research. A unique selling point is necessary. It is gratifying therefore to welcome and endorse the publication of Health Geographies: A Critical Introduction. It is an important and necessary addition to the literature that takes us to the current frontiers of inquiry in health geography, engaging the reader with the social, the cultural, the political and the epidemiological, and doing so in a way that highlights the importance of geography. The text offers a critical perspective and brings us a health geography that is mature, confident and theorised, able to build on secure foundations and move forward. Interdisciplinary in reach but firmly anchored in geography, the authors have drawn deeply on their research and teaching expertise to assemble a systematic overview of the topics that have emerged at the cutting edge of the health geography in the past few years. Ideas about place, wellbeing, care, identity, relationality, complexity, biopolitics and global health are now increasingly commonplace in health geography but, to date, we have lacked a critical assessment. In addressing this need, the authors have ably navigated the challenges of summarising complex ideas, working with theory, and setting out a critically‐engaged analysis. The results of their labours should provide undergraduates and commencing graduate students with the necessary background to understand and contribute to the further development of a critical health geography.
Graham MoonSouthampton, 2016
Acknowledgements
This book project was first initiated in 2009, and Tim would like to thank Susan Craddock for allowing him to take their original proposal forward. As with any such project, the book has undergone a number of subsequent iterations and we would like to thank anonymous reviewers for their comments on the proposal and draft manuscript. We would also like to thank everyone at Wiley‐Blackwell for all their hard work and also for their patience. It is also important that we acknowledge and thank colleagues and students (past and present) whose conversations and exchanges have helped us to hone our critical edge. Finally, we would like to pay special thanks to Graham Moon who read and commented on the draft manuscript, and who ultimately helped us to recognise the importance of what we were collectively trying to achieve.
Chapter 1Introduction
Introduction
The task of introducing a book such as this is not inconsiderable, especially as it has been co‐authored by scholars who place themselves very differently within, and in some cases without, the field of health geography. We should be clear about this latter point right from the outset. This text is a critical introduction to health geographies – deliberately presented in the plural rather than the singular form – and it is written by scholars with different and sometimes quite jarring epistemological perspectives and ontological positions. Like many of our contemporaries, we do not see health geography as a single field of study and how we each approach the question of health differs considerably. Moreover, some of us are less concerned with health as an object of investigation than we are with subjects that appear to fit a little more comfortably under the rubric of medical, or perhaps more appropriately biomedical, geography. For example, there is as much focus on disease and biomedicine in this textbook as there is on questions of health and health care. In practice, then, this book works across disciplinary and sub‐disciplinary boundaries that have been established by those writing within the field (e.g. Kearns 1993; Mayer and Meade 1994; Kearns and Moon 2002; Rosenberg 2016) but perhaps tend to overlook what is going on outside of it (e.g. Parr 2004; Philo 2000, 2007; Dorn et al. 2010).
As a second point of introduction we should also say a little about why we targeted our ideas for this book at the Wiley‐Blackwell Critical Introductions to Geography series. You will be aware that there are numerous textbooks covering the field of health geography, from Kelvyn Jones’ and Graham Moon’s (1987) classic Health, Disease and Society: An Introduction to Medical Geography to more recent, and sometimes a little more specialist, texts such as Robin Kearns’ and Wilbert Gesler’s (2002) Culture, Place and Health, Sarah Curtis’ (2004) Health and Inequality, Anthony Gatrell’s and Susan Elliott’s (2009) Geographies of Health: An Introduction and Peter Anthamatten’s and Helen Hazen’s (2011) An Introduction to the Geography of Health. To these texts on health geography, we might also add Melinda Meade’s various editions of Medical Geography (e.g. Meade and Emch 2010). Each of these books offers their readership invaluable insights into the field, however we were struck by the idea that the Wiley‐Blackwell series is committed to providing ‘broad and introductory’ textbooks with a ‘critical edge’. It was the emphasis placed upon criticality that was especially important to us and we believe should be important to you as readers. Here, it is not only a matter of how criticality is defined by us but how this commitment to criticality should shape the ways in which you approach this text. We will deal with the former of these points in the section that follows, but as readers we encourage you to examine the evidence that we present and consider the theoretical influences upon it. Be sure to interrogate the interpretations that we offer and to reflect on possible alternatives to them; think, for example, about what is present and what is absent in our readings of the field. Ask yourselves how persuaded you are by the arguments and opinions that we present and the conclusions that we draw. In sum, you should be aware that we have made decisions in our research and writing and we encourage you as readers and potential future authors to enter into academic debate with us.
A Critical Introduction to Health Geography?
If we take a fairly straightforward view of what health geography is concerned with, we might suggest that it questions how the interaction of humans, materials and the environment shapes and constrains health, wellbeing, survival and flourishing. At the heart of this interaction are complex social, economic and political issues which can complicate and extend conventional debates about health. An examination of these issues and how they affect people around the world, often very differently, can unearth a myriad of health costs and benefits. For example, rising conflict in the Middle East has been quickly followed by outbreaks of polio, which has re‐emerged because efforts to immunise children are being hampered (Blua 2013). Meanwhile, more than 5 billion people worldwide now have a cell phone, leading to a number of efforts to use mobile technology to revolutionise the way medical care and health information are delivered, particularly in the rich countries of the Global North (Hampton 2012). In each case, health is entangled with complex ethical, social and political concerns over the autonomy, control and care of humans. These are concerns that demand critical health geographers engage with ideas, debates and perspectives from outside of their direct fields of interest. Equally our response to them ensures that we contribute to knowledge and understanding of a multitude of health and biomedical issues that is interdisciplinary in nature.
So health geography is a broad field of enquiry, as this book amply demonstrates. Yet, we agree with Robin Kearns and Damian Collins (2010) when they state that at the core of the sub‐discipline lies, or at least should lie, a concern for social justice. This is as good a place to start as any when considering the question of what a critical introduction to health geography might entail. This concept evolved from foundational principles associated with the ‘social contract’ (for a full history of this concept, see Rawls 1971). The social contract is the recognition that individuals have rights such as dignity and autonomy with which the state cannot unduly interfere. Individuals allow the state to rule only through laws which, at least in theory, pursue the principles of freedom and equality. This ‘pact’ allows society to function as a whole and gives legitimacy to the authority of the state over the individual. Of course, since these early foundational principles, different interpretative theories of social justice have developed which sit on top of the foundational principles. Governments have tended to have either a ‘right’ (liberal) or ‘left’ (social democratic) political understanding of the social contract. On the right, governments tend to interpret the social contract to mean the minimum possible role of the state: individuals should be completely untethered to pursue their own ends. The state is despised as a wasteful villain that obstructs the self‐equilibrating market system. The corollary is that the state provides minimum protections to those who ‘fall between the cracks’. On the left, governments tend to interpret the social contract to mean the state should provide a more supportive role and protect against the more self‐destructive forces of the capitalist system.
When considering this question, critical health geographers must therefore be cognisant of the underlying political philosophies of the state as they can have significant effects on the health of individuals. A value judgement can be made about the social justice element of particular policies and their impacts on certain individuals, groups or even the population as a whole. For example, Danny Dorling’s (2014) geographic work in the United Kingdom has mapped the health and distribution of wealth of its citizens and argues that as a result of the British state’s commitment to neoliberal policy, including the more recent politics of ‘austerity’, the mere accident of being born outside the nation’s wealthiest 1 per cent will have a dramatic impact on the rest of your life: it will reduce your life expectancy, as well as educational and work prospects, and affect your mental health. To Dorling’s voice we can add that of Clare Bambra who, in her work with Ted Shrecker, recently argued that there are clear parallels between the health effects of neoliberalism and the ‘unfettered liberal capitalism of the 19th century’ (Shrecker and Bambra 2015, p. 17). Specifically, they argue that now as then the conditions in which people live, work and play are vital in determining how long and in what state of health people live.
Collectively, this work serves as a useful example of how to be ‘critical’. The value judgements presented by all of these scholars are drawn from thoroughly‐researched, empirical findings. Based upon their generally realist epistemological positions, Dorling and Bambra recognise what evidence is essential to validate their argument as well as how much evidence is needed to support their conclusions. However, an important caveat here is that to be critical, one should remain equally alert to the nature of evidence itself. For example, the idea of evidence‐based health care (EBHC) has quickly become a global priority. Yet, the wide‐ranging critique of EBHC highlights that, although it is appropriate that the best health care is provided in the best known ways, EBHC goes far beyond this objective, becoming a powerful movement in itself that espouses a dominant scientific worldview that selectively legitimises and includes certain forms of knowledge but degrades and excludes other forms, such as qualitative ones. Critical health researchers argue that, in response, a critique is necessary for deconstructing this mode of thinking, and that resistance is ethically necessary given the powerful forces in play (Holmes et al. 2007).
Another way of thinking about the criticality of this work is to focus on the philosophical and social theoretical perspectives that it draws upon. As Hester Parr (2004) argued some time ago now, critical geography is, among other of its key aspects, broadly defined as research work that is relevant, interdisciplinary, cutting edge and theoretically sophisticated. While Dorling’s and Bambra’s work does not necessarily pay too much attention to some of the other characteristics of critical geography that Parr outlined (notably those that relate to the ‘theoretical gymnastics’ that we might associate with the ‘cultural turn’), it can be argued to mirror these other elements. For example, Dorling implicitly draws on the Marxist philosophy of unequal ownership of wealth to help make sense of his empirical observations and provide new ways of understanding the complex matters of health, wealth and illness. Similarly, Shrecker and Bambra offer an account of contemporary health and health care that demands we pay close attention to the neoliberal political philosophy that underpins many of the policy decisions that are made around the world today. Being able to theoretically (re)interpret research is an important way of making sense of empirical observations, as it allows us to disentangle and articulate some of the underlying meanings and processes involved. We may not all agree with the particular theoretical and for that matter political perspectives that we encounter but it is important to recognise that academics use theory to frame how they see the world and as critical health geographers we need to question this as well as consider theoretical possibilities other than those presented to us.
Of course, to be critical does not limit us as health geographers to only addressing those topics that are most closely aligned with questions of social justice. As Lynn Staeheli and Don Mitchell (2005) note in their analysis of the politics of relevance, what counts and does not count as relevant, and by extension critical, research is defined in many ways. For example, for some of the geographers that they interviewed in their research, relevance was linked to the kinds of political commitment and wider social impact demonstrated by Dorling and Bambra in the above discussion. Outside of this, relevance can also be defined in terms of the pertinence of research – the timeliness of an issue with regard to a particular time and place, as well as in relation to questions of the applicability of research – the ability of research to be applied or to result in some kind of action. Although these two values may appear to be constraining, especially on research that is more theoretically oriented, Staeheli and Mitchell reveal that this does not necessarily have to be the case. Referring to interviews that they conducted with Michael Dear and Jennifer Wolch, whose research we refer to later on in the book (see Chapter 6 and Chapter 7), Staeheli and Mitchell note that theoretical work is not only necessary to the development of research and to its communication but also to ‘bringing to light issues and ways of thinking that might change how people understand problems or evaluate what is important’ (2005, p. 370). Though questions of social justice are relevant here, so too are many other social issues and the various possible responses to them of interest to health geographers.
Critical research demands that we do not simply accept the world as it is presented to us in political announcements, policy briefings or in empirically‐oriented, atheoretical research. Instead, critical researchers are encouraged to familiarise themselves with relevant literature, theories and research methods, as well as be cognisant of their own values, assumptions and epistemological and ontological positions. In so doing, researchers place themselves in a position to be able to challenge social and institutional norms, models of thinking and hegemonic power relationships. With this goal in mind, critical health geographers often pay close attention to people and issues that are neglected or marginalised in mainstream society. It is observed that certain people – often deemed the most vulnerable – ‘fall off the map’ of policy, practice and research. We might think here of those least able to care for themselves, for example the young and the elderly, the mentally ill or physically incapacitated, or populations who are placed on society’s margin because of their sexuality, race or ethnicity, class position or housing status. However we define vulnerability, and it is a complex question that deserves careful consideration, it is up to critical researchers to challenge neglect and expose the lived experience of people in their everyday encounters with social relations of power. As Blomley (2006) suggests, as critical geographers we should promote solidarity with people, particularly those who are the oppressed and victimised, and this book is certainly attuned to this ideal.
To extend this perspective on criticality a little further, another important facet of being a critical health geographer is exploring and questioning everyday practices and their complex inter‐relationship with the spaces and places which we co‐inhabit with other human and non‐human entities. Health geographers are interested in the everyday in many different ways, for example, in terms of the decisions that people make or the routines and practices in which they partake (e.g. whether to eat ‘5 a day,’ consume alcohol or smoke tobacco products or take part in risky sexual practices) and the socio‐environmental conditions under which people live and work and the differential effects of these on their ability to access health care services and health‐related resources. We might also focus in on the experiences of individual citizens – often, but not only, when they are reconstituted as patients, risk groups or as healthy or diseased subjects, as well as on the significant role of health professionals, health care commissioners and policy makers and increasingly bioscientists and pharmaceutical companies in helping to shape these experiences. Crucial to our understanding of the everyday is not only that we account for those processes that (materially) structure people’s experiences, but that we also recognise that these experiences are contingent upon the spaces and times within which people live. Here, it is vital that we acknowledge that the identities people assume and those that are socially ascribed to them – whether based on race/ethnicity, class status, sex and/or sexuality, ability/disability and so on – will be important in differentiating these health‐related experiences and their consequences for people’s health and wellbeing. Moreover, we argue throughout this book for a concern with the modes of governance – often referred to under the Foucauldian concept of biopolitics – that help to shape and reconfigure the kinds of behaviours and practices discussed, as well as our understanding of the bodies who willingly or otherwise perform them.
Finally, as critical health geographers it is important to remain alert to the differential effects of mobility and scale on health as well as on their relevance to our understanding of disease and biomedicine. Geographers sitting outside of the sub‐discipline of health geography, as well as other social scientists, have been particularly attuned to these questions. The case of severe acute respiratory syndrome (SARS), which we explore in Chapter 11, is an especially good illustration of this. In their edited volume covering the epidemic, Networked Disease: Emerging Infections in the Global City, Harris Ali and Roger Keil draw on a quote from the former Director‐General of the World Health Organization (WHO), Gro‐Harlem Brundtland, which is especially helpful in highlighting the importance of scale: ‘Today public health challenges are no longer local, national or regional. They are global’ (Brundtland 2005. Cited in Ali and Keil 2009, p. xix. Emphasis added). The point being made here is one that geographers are, of course, fully alert to and that is the idea that local situations and events are increasingly closely related to global scale processes. SARS was an especially powerful illustration of this because of the rapidity with which a relatively localised epidemic – one whose origins lay in the economic and cultural practices associated with the production and consumption of civet cats in the Guangdong province of China – was transformed into the first major pandemic of the twenty first century in part because of the global cities network through which it was primarily transmitted.
The chapters in this edited volume not only offer accounts of the transmission process, they also provide important insight into wider sets of questions relating to the processes of globalisation and the hypermobility of pathogens such as the coronavirus that caused SARS, for example the interplay between human and non‐human agents, the challenges that such hypermobility places upon public health strategies of containment and control, as well as the pathologisation of highly mobile human bodies and the closely related problem of their subsequent stigmatisation. Of course, it is not only infectious diseases and the pathogens that cause them that are mobile and multi‐scalar in their effects and as such the target of critical health scholarship. Similarly to SARS and other emerging and re‐emerging infectious diseases, it is also increasingly recognised that the so‐called ‘global obesity epidemic’ is caused by processes – namely risk factors associated with diet and physical inactivity – that were once believed to be confined to affluent nations in the Global North but are now global in their reach. As Tim Brown and Morag Bell (2008) have commented, non‐communicable diseases are considered to be transmissible across borders due to their being linked to risk behaviours, which, according to a joint report by the WHO and the Food and Agriculture Organization, ‘travel across countries and are transferable from one population to another like an infectious disease’ (WHO/FAO 2003, pp. 4–5. Cited in Brown and Bell 2008, p. 1575).
Applying a Critical Perspective to Our World
Drawing on this loose typology of critical research above, and the inherent lessons for how such an approach can be used, our book seeks to develop understanding by focusing on the main debates and thematic areas that we argue define critical scholarship in health geography research. From our work in the field of health geography, which for us also includes topics that might otherwise be covered under the rubric of medical and biomedical geographies, we distil five key cross‐cutting critical themes that extend across all the chapters of this book. Some are more obviously relevant to, or explicit in, some chapters than in others and we do not claim that this list is exhaustive. Nonetheless, given that each contributor to this book is firmly committed to advancing critical health geography debates, we argue that the five themes serve as important rallying calls to begin to explore the myriad and diverse issues and trends with which the book engages, therefore allowing you as a reader to punctuate such debates. While the themes are not necessarily ‘new’, we argue first that they have entered new stages in their depth and breadth of reach, and second that they have become increasingly entangled and intersected with each other, thus creating new forms and new spaces entirely. Taken together, they therefore have a cumulative effect on the health of people around the world and, we argue, can either exacerbate or ameliorate many of the challenges people face in their everyday lives.
Neoliberalism
Whilst being an ideology rooted in earlier liberal philosophy and a blueprint for the 1970s Thatcher–Reagan government projects in Anglo‐America, neoliberalism has arguably entered a new phase in terms of its breadth and reach. In the wake of the financial crisis of 2007–2008 and its prolonged aftermath, governments in many countries, particularly in the Global North, have resorted to policy measures that seek to reduce the role of government – although as argued later, it has hardly reduced bureaucratic control in many areas involving welfare and support – as well as implemented deregulation, privatisation, outsourcing and competition in public services. Governments have imposed strict fiscal discipline and cut public spending in the hope of restoring budgetary integrity and securing the confidence of investors. These measures are argued to be essential in order to pave the way to renewed economic growth.
Interestingly, this has largely been done without neoliberalism being mentioned by the political parties that drive it. Its anonymity, according to George Monbiot (2016), is both a symptom and cause of its power: ‘So pervasive has neoliberalism become that we seldom even recognise it as an ideology’ (Monbiot 2016). Its creeds have become internalised and reproduced with little thought. According to Monbiot’s argument, the result of this internalisation has been that the rich (can) persuade themselves that they acquired their wealth through merit, ignoring the personal advantages – such as education, inheritance and class – that may have helped to secure it. Meanwhile, the poor begin to blame themselves for their failures, even when they can do little to change their circumstances. While neoliberalism has gone incognito in a very short space of time, the political dogma of ‘austerity’ has become the catchword for the renewed attempts to cope with ‘post‐crisis’ uncertainties at different spatial scales (Blyth 2013, p. 2; Peck 2012, p. 626). With neoliberalism firmly positioned as the dominant economic policy script, the tension between the right and left politics mentioned above has come to be increasingly resolved in favour of right‐wing austerity. David Featherstone and colleagues talk about ‘austerity localism’ whereby ‘localism is being mobilised as part of an “anti state”, “anti public” discourse to build support for an aggressive round of “roll back” neoliberalism’ (Featherstone et al. 2012, p. 177).
In terms of breadth, neoliberal policy has expanded across Europe, North America, Latin America and Africa, although of course it remains always incomplete and existing in myriad different forms. In Asian nations, for example, ‘coordinated market capitalism’ exists whereby institutions coordinate many of the most important economic decisions and functions (e.g. wage setting, bargaining, business/labour management of social programmes) (McGregor 2001). Nonetheless, despite its hybridity, through the IMF, the World Bank, the Maastricht Treaty and the World Trade Organization, neoliberal policies have been imposed – often without democratic consent – on much of the world (see Chapters 11 and 14). In terms of its depth of reach, it has also become more firmly embedded in political and economic contexts and in terms of the level of impacts on the ground. One of the most pressing concerns relating to neoliberalism in health geography is the withdrawal of the state from health and social care. Freedom from collective bargaining and trade unions has meant the freedom to suppress wages. Freedom from tax has meant a freedom from the distribution of wealth that lifts people out of poverty and poor health. The post‐war consensus that the state is best placed to provide comprehensive health care no longer has widespread credence. In the UK for example, the Institute for Fiscal Studies (2015) drew the conclusion that the Conservative manifesto of public sector cuts would reduce state and social spending to pre‐(World War II) welfare state levels.
Under neoliberalism, state health care is seen as inefficient and private markets are seen as more cost‐effective and consumer‐friendly. The neoliberal agenda of health care reform includes cost cutting for efficiency, decentralising to the local or regional levels rather than the national levels and setting up health care as a private good for sale rather than a public good paid for with tax revenue (McGregor 2001). Austerity budgets have led to reductions in community services, such as the closure of day centres (Hall 2014). Meanwhile, in the Global South, some of the initiatives led by international organisations under the flag of development were counter‐productive in many contexts, such as the Poverty Reduction Strategy Papers introduced by the World Bank and the International Monetary Fund in 1999, which ultimately reduced health service expenditure in several African countries (Navarro 2007, p. 354; see also discussion of SAPs in Chapter 14). Alongside the decline in state health care provision, epidemics of self‐harm, eating disorders, depression, loneliness, performance anxiety and social phobia are being increasingly documented (Verhaeghe 2014). Social care users risk ‘moving from a position of enforced collectivism to an enforced individualism characteristic of neoliberal constructions of economic life’ (Roulstone and Morgan 2009, p. 333). Readers of this book should therefore remain alert to the idea of the political shaping of health and the politics of vulnerability. Those at the front line in health care provision often have little time to engage critically with such debates, and yet they must deal with the pragmatic challenges of reduced budgets.
Inequality
Disadvantage is patterned across a range of spatial scales from the local to the global, and within and between populations of interest. The existence of inequality relies on the social, economic, political and cultural ordering of people and place and is thus not a naturally occurring property of society but a product of the way we live now and the ways we have lived. As a cross‐cutting theme in this book, inequality is both the precondition and outcome of the other themes we identify, acting reciprocally to either deepen or ameliorate experiences of disadvantage according to individual circumstance.
As indicated in the earlier discussion, Dorling’s (2014) work illustrates the growth of inequality within the British context. But Britain typifies a growing trend in both Global North and South countries towards an unequal accumulation and distribution of wealth. In Stiglitz’s (2015) The Great Divide, he traces the massive growth of deregulation, tax cuts, and tax breaks for the 1 per cent in the United States and argues that many are falling further and further behind. In a global comparison, according to the World Bank Gini coefficient (2015),1 many of the wealthiest nations in the world such as the United States (calculated at 0.41 out of 1) and the United Kingdom (0.38) are in a race to the bottom of the global league tables of wealth inequality. Those deemed as the most unequal include nations such as Brazil (0.53), Haiti (0.59) and Colombia (0.54). According to the Organisation for Economic Co‐operation and Development (OECD), Britain serves as a pertinent example, as it was once deemed one of the most equal countries in the post‐war period of the 1950s.
What has driven these increases in inequalities? While there is no consensus, it is argued that one key reason has been the rise of globalisation and skill‐biased (task‐biased) technological change and institutional change. However, critical researchers also argue that social policy, particularly tax and benefit policy, no doubt also plays a key role in modifying these external pressures. Indeed, David Harvey’s (2000) central thesis argues that inequality stems from a class‐based political project rooted in the global neoliberal philosophy, thus creating new means of capital accumulation. Inequality is often employed as a proxy for social justice, discussed earlier as a key motivator for health geographic research, particularly as an indicator of ‘distributional fairness’ or ‘distributive justice’. These terms capture how resources are differently allocated in a society and owe their prominence to early work such as Harvey’s Social Justice and the City (1973) and David M. Smith’s Human Geography: A Welfare Approach (1977). A range of terms have been used in the literature to describe situations of (in)equality, most notably including (dis)parity, (in)justice and (in)equity. As Paula Braveman (2006) elucidates in an annual review, there is little consensus about the practical differences between these terms but they nonetheless remain important concepts nationally and internationally to governance and policy. The enduring value of inequalities work is evidenced by the range of recent publications that describe the disadvantage of some within a society compared to others as inherently detrimental to its functioning: Richard Wilkinson and Kate Pickett’s (2009) The Spirit Level, Danny Dorling’s (2010) Injustice and Thomas Piketty’s (2014) Capital in the Twenty‐First Century.
In health geography, early work on inequality sought to characterise disadvantage, particularly economic disadvantage, as leading to the development and widening of a number of health ‘gaps’ between the various occupational social classes. This was the approach adopted by the UK Government in the influential Black Report (DHSS 1980) in which an expert committee led by Sir Douglas Black demonstrated the existence of widespread inequalities in population health (see Chapter 10). The report showed that at the time of its publication, people belonging to the lowest occupational social group, ‘unskilled workers’, had a death rate twice that of the highest occupational social group, ‘professional workers’. The objective of public health policy at the time became the narrowing of the gaps between social classes in light of evidence that suggested that these gaps were widening. The narrative of health inequalities has continued ever since in public health policy in the United Kingdom and globally; however, we now no longer think of health inequality as being the presence of ‘gaps’ between the richest and poorest, rather we talk in terms of a ‘social gradient’ of inequality in health.
The expression of health inequalities from gap to gradient owes much to the work of Sir Michael Marmot, who chaired the Marmot Review (see Marmot et al. 2010), and his team who evidenced that rather than a gap there was a continuous gradient in life expectancy in the continuum from most to least deprived. Academic and policy‐based characterisations of inequality have been complemented by more populist accounts, such as Danny Dorling’s (2013) The 32 Stops, which narrates inequality along the London Underground’s Central Line. This project reflects work by the London Health Observatory whose diagram (see Figure 1.1) shows the inequality in male life expectancy along the London Underground’s Jubilee Line. James Cheshire (2012) subsequently produced a web map called ‘Lives on the Line’ (see http://life.mappinglondon.co.uk/, visited on 21 April 2016) which maps life expectancy at birth and child poverty, as well as other social determinants of health, according to the London Underground network for the entirety of Greater London. Similar maps have been produced for other major British cities, and revealing the extent to which public health professionals and academic researchers have highlighted an issue that a Conservative government under the leadership of Margaret Thatcher sought to conceal with the shelving of the Black Report (Schrecker and Bambra 2015).
Figure 1.1 Male life expectancy on the Jubilee Line, London.
Source: London Health Observatory, 2012. Contains public sector information licensed under the Open Government Licence v3.0.
Globalisation/urbanisation
The notion that inequality solely captures differences in the allocation or distribution of resources has been useful for health geographers, wherein access to material resources can be readily quantified and compared for different groups of people and used to inform arguments about what is ‘fair’ or ‘just’. However, a critical insight suggests that inequality should extend also to capturing less immediately tangible concerns. Doreen Massey, for instance, developed ‘power geometry’ (1993) as a way of connecting notions of power to the global flow of people and the differential effects of globalisation. David Harvey, again, demonstrates the relational nature of space, place and time to social and environmental justice in Justice, Nature and the Geography of Difference (1996). This leads us to our third cross‐cutting theme, which is globalisation and, closely associated with it, urbanisation.
The growth in specialisation, information and communication technologies and mobilisation of people has become a key characteristic of the early twenty first century. In parallel with these human endeavours, global climate change continues to loom as a growing risk to the Earth’s environment and to the health and wellbeing of us all. This is clearly evident from the rhetoric of international health organisations such as the WHO, whose current Director‐General, Dr Margaret Chan, stated that:
Population growth, incursion into previously uninhabited areas, rapid urbanization, intensive farming practices, environmental degradation, and the misuse of antimicrobials have disrupted the equilibrium of the microbial world. New diseases are emerging at the historically unprecedented rate of one per year. Airlines now carry more than 2 billion passengers annually, vastly increasing opportunities for the rapid international spread of infectious agents and their vectors. … These [and other] threats have become a much larger menace in a world characterized by high mobility, economic interdependence and electronic interconnectedness. Traditional defences at national borders cannot protect against the invasion of a disease or vector. Real time news allows panic to spread with equal ease. Shocks to health reverberate as shocks to economies and business continuity in areas well beyond the affected site. Vulnerability is universal.
(WHO 2007, p. iv. Emphasis added)
Thus, to global inequalities in wealth and the associated challenge of ‘Closing the Gap’ highlighted by WHO’s Commission on the Social Determinants of Health, under the chairmanship of Sir Michael Marmot (Marmot 2008; see Brown and Moon 2012), we can add health problems linked to the economic, social and political consequences of an ever greater concentration of the world’s population in urban centres. As the Population Division of the UN’s Department of Economic and Social Affairs reported, over half of the world’s population now live in urban areas and by 2050 this figure is projected to reach 66 per cent (United Nations 2015, p. 1). More significantly, some 90 per cent of this growth is estimated to occur in Asia and Africa. As Clare Herrick (2014, p. 557) states, the conditions under which many people live in the megacities that are emerging from this process of urbanisation, especially, though not only, those in the Global South, threaten to ‘unravel the “urban advantage”’ received by urban dwellers who are believed to benefit from better education, higher incomes and improved access to employment opportunities, health care services and so on. As she notes, the question is not so much of an ‘urban advantage’ but of an ‘urban penalty’, which returns us to debates about the health consequences of rapid urbanisation experienced in the nineteenth century (see Kearns 1991).
How we approach these questions as critical geographers will vary. Undoubtedly there are many health geographers whose focus will remain on questions of social justice and the closely aligned issue of (global) health inequalities. Others may concentrate on the discursive construction of spatially distant, hypermobile populations as the ‘Other’, especially when they become associated with the movement of infectious diseases such as AIDS/HIV, SARS and Ebola from ‘there’ to ‘here’ or, put differently, from ‘the rest to the West’ (Hall 1992). However, Herrick’s call for a much greater focus on the urban in these questions of globalisation and global health is a timely and important one. This is so not only because urbanisation is helping to intensify processes that are responsible for many of the health problems that the world now faces, as exemplified in the quote from Chan. It is also because the urban has often been overlooked in the responses of what Herrick refers to as the ‘Global Health’ enterprise; as she argues, the urban question is an ‘implicit rather than explicit area of activity, investment and activism’ when it comes to addressing global health issues (2014, p. 561). Although this book does not respond to Herrick’s call as effectively as it might have, we certainly recognise the importance of the issues that she raises to critical health scholarship in the future.
Biopolitics
A concept generally ascribed to the French philosopher, Michel Foucault, biopolitics describes the political governance and control of the ‘bio’ of people (their bodies and minds). Biopolitics has arguably become more relevant as the modes and techniques of controlling, tweaking and ‘nudging’ people’s bodies have grown more elaborate and fine‐tuned in the political orchestration of health and social care policy (see Chapter 2). Whilst biopolitics has been around for a long time – indeed since the original ‘social contract’ emerged – its growth in scientific, technological, bureaucratic terms has arguably surpassed previous eras in the extent and degree of subtlety to which the state can manage the everyday lives of individuals.
Nikolas Rose and Carlos Novas (2004, p. 440) suggest we might think of the ways in which biopolitics has effectively remade citizens into ‘biological citizens’. They define biological citizenship as ‘all those citizenship projects that have linked their conceptions of citizens to beliefs about the biological existence of human beings, as individuals, as families and lineages, as communities, as population and races, and as a species’. In this way biology is used to determine what constitutes normal, healthy bodies or citizens and those bodies seen as being unhealthy or deviant. The crafting of biological citizenship can be seen in the formation of state policies and interventions that target the population as biological beings. For example, in welfare policy, psychology now plays a central and formative role in stigmatising the existence and behaviour of various categories of poor citizens and in legitimising the measures taken to transform and activate them. Rather than blame structural causes of unemployment, these strategies can perpetuate notions of psychological failure and shift attention away from wider social and economic trends, including market failure, precarity and the scale of income inequalities, towards individual weakness. In Britain for example, recent workfare assessments have led to severe sanctioning of those who are judged to be not complying with an increasingly elaborate set of demands. Inherent in these policies is a summoning of various citizen‐subjects such as the responsible citizen, the active citizen, the democratic citizen, the citizen worker and so on (Newman 2013).
Another example of biopolitics in health and social care is seen in the implementation of personalisation policy. While originating as a response to inflexible group disability services, personalisation shifts the emphasis of what service people want towards what kind of life a person wants. Inherent in this approach is the choice afforded to individuals. While this goal is of course laudable and has been shown to have positive outcomes for disabled people, its implementation during a time of austerity has led to the wholesale shift in responsibility to the individual (Power 2014). Those eligible for social care are in effect having to become managers and ‘sole‐traders’ of their own care. This means disabled people have to now manage insurance and employment related tasks associated with arranging support as well as their own personal lives.
