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الأربعاء، 14 مارس 2018

From medical to health geography: novelty, place and theory after a decade of change


From medical to health geography: novelty, place and theory after a decade of change 

Robin Kearns

School of Geography and Environmental Science, The University of Auckland, Private Bag 92019, Auckland, New Zealand

Graham Moon
 
Institute for the Geography of Health, University of Portsmouth, Mildam, Burnaby Road, Portsmouth PO1 3AS, UK


Progress in Human Geography 26,5 (2002) pp. 605–625 

Abstract: In this paper, we reflect on the positioning of health geography within the wider academic landscapes of geography and health-related research. Drawing on examples from a number of countries, we consider the extent to which a ‘new geography of health’ has emerged in recent years. We structure our discussion around the themes of place, theoretical engagement and critical relevancy. Changes within the subdiscipline are placed in the context of a central question: what is new about the new geography of health? 

Key words: health geography, medical geography, disciplinary development.

I Introduction 

  In geography, as in other disciplines, fashions and emphases change. At certain times, some research themes gain respectability, become ‘trendy’, attract graduate students and provide a focus for investment, while other themes go into decline. These changes have long been recognized as central to the development of knowledge and scientific thought (Kuhn, 1962; Lakatos, 1970). In geography, the process has been signalled in the successive editions of Geography and geographers (Johnston, 1997) and The dictionary of human geography (Johnston et al., 2000). Thus, within the relatively recent past, the onetime ‘moribund backwater’ of political geography has been reinvigorated (Painter, 1995), there has been a reappraisal of regional geography (Sayer, 1989), cultural geography has engaged with cultural studies and post-structuralism (Mitchell, 2000; Jackson, 1993) and there has been editorial consideration of the ‘new economic geography’ within the pages of Transactions (Martin, 1999). In each of these examples, the attachment of the prefix ‘new’ to the research area concerned has intimated a major change, a break with a past and a new beginning. New developments have been contrasted with past concerns and approaches, with accompanying implications regarding progress and the enhancement of knowledge.

   Our goal in this paper is to interrogate the process of subdisciplinary change as it has affected the geography of health. We consider whether there has been significant transformation over the past decade. This period has, for some, seen a marked quickening of a process of metamorphosis that has shifted ‘medical geography’, a minority concern and a ‘confusing sub-variety’ of human geography (Haggett, 1965: 1), to a confident, recognized and distinct ‘geography of health’ (Rosenberg, 1998). The shift has been portrayed as indicative of a distancing from concerns with disease and the interests of the medical world in favour of an increased interest in well-being and broader social models of health and health care. Texts, journals and reviews have accompanied, and propelled, the emergence of this (new) geography of health. Importantly, however, this process of academic development has been, and continues to be, contested. While, on the one hand, this may be taken as indicative of healthy debate, it also raises a crucial question about the nature of the new geography of health: to what extent has research practice actually changed? In this deceptively simple question lie more fundamental matters concerning the nature of novelty, progress in academic research, and the constraining aspects of the wider environments in which research is conducted.

  We seek to interrogate the foregoing concerns through a survey of the contemporary history of the geography of health. Our goal is to think through what is ‘new’ in the new health geography. Novelty has a number of connotations including something unusual, an innovation, a breakthrough and a fad. Here our analysis focuses on establishing difference, on identifying a clear and marked change in the concerns of the subdiscipline. We chart what is novel about health geography through the identification of three salient themes: the emergence of ‘place’ as a framework for understanding health, the adoption of self-consciously sociocultural theoretical positions, and the quest to develop critical geographies of health. We examine the extent to which these themes have characterized research practice and draw conclusions that take account of the political and practical context in which research practice has taken place. As a necessary prelude to this examination, we begin with a brief review of the emergence of the new geography of health, noting, in particular, the claims and ambitions articulated in various programmatic statements as well as counterclaims, cautionary exhortations and sceptical critiques. 

II Medical and health geographies 

  In this section, we trace the changes in scholarship that have led to the emergence of socalled ‘new health geographies’. Our argument is that, although programmatic statements on potential new directions for a research area may have a paradigmshifting ring about them, in reality social scientific research programmes seldom shift rapidly or radically. As Martin (1999) noted with respect to the purported colonization of geography by economics, although academic disciplines are predicated on the search for novelty, the development of knowledge is seldom sudden. Evolution, rather than revolution, tends to be the case. The clarion calls of reformers, we suggest, speak with the goal of catching attention and moving the middle ground of dominant discourses. Thus, contemporary health geography, if it is distinguished by novelty, will have changed as a consequence of a collective, but contested, openness to the ideas of other disciplines as well as other constituent fields of geography. As we go on to discuss, one issue here is the balance between change in health geography as a process developed from within the subdiscipline and the alternative possibility that any new health geography has simply mirrored, with some lag, developments elsewhere.

   As a starting-point for our analysis, we begin with an assertion made over a decade ago. Bentham et al. (1991: ix) noted that ‘. . . medical geography is often a lonely discipline’. Biennial international medical geography symposia were identified as breaking a solitude that was often evidenced in poorly attended sessions at general geography conferences. Symptomatic of this solitude had been a certain introversion of concern during the 1970s and 1980s. Disease ecology and health services research had tended to be distinctive streams of work, albeit streams that were widening (Mayer, 1982; Jones and Moon, 1987). This ‘twin streams’ model contrasted studies of disease distributions or diffusion with welfarist and largely empiricist studies of health care provision. By the 1990s, however, Bentham and colleagues (1991: ix) felt able to argue that: ‘. . . the dichotomy is becoming increasingly blurred as experience has shown that important research problems straddle the boundary. These rather inward-looking concerns have been replaced by an increasing openness to influences from the outside.’ Thus perhaps the most important development over the last decade has been that the twin streams of medical geography have intertwined (Moon et al., 1998). To pursue the fluvial metaphor, health geography has become more like a braided river. Furthermore, growing connections have been made with developments outside the immediate confines of traditional medical geography praxis.

   Symbolic of this process has been a widespread rearticulation of medical geography as health geography. As Del Casino and Dorn (1998) argue, such a renaming might too easily embody new and less than helpful sets of dualisms such as new/old, and traditional/contemporary. Despite using the latter dyad, Curtis and Taket (1996: 22) suggest, however, that the emphasis has been on complementarity rather than competition. Indeed, the enduring persistence of the twin streams of medical geography alongside ‘new’ or ‘contemporary’ concerns is, perhaps, a strength in so far as a catholicity of interests can appeal to a wide constituency. The contemporary challenge is therefore, as Berg (1994) argues, to avoid being distracted by binary discourses that inevitably privilege one partner in dualities such as theoretical/empirical and contemporary/traditional. 

    Through the 1990s, the purported transition from medical to health geography can be charted through reference to various key publications. The reports on medical geography in Progress in Human Geography; provide our first indicator of these shifting concerns. To date, these reports have tended to be deliberately framed as catalysts for change, with reviewers eschewing the temptation of simply cataloguing recent publications in favour of exploring potential avenues for novelty (Jones and Moon, 1991; 1992; 1993; Kearns, 1995; 1996; 1997; Hayes, 1999). What is important to note is that these essays often look outside health geography, and indeed outside geography itself, at areas in which health geography might frame knowledge or where such a framing had already begun. 

  A second group of publications was, at least initially, more inward-looking. A paper by Kearns (1993) attempting to nudge the collective focus of medical geography towards a cultural/humanistic standpoint through the advocacy of ‘post-medical geographies of health’ led to a debate in the pages of The Professional Geographer. This ‘post-medical’ challenge, seeking to shift the subdiscipline from a concern with disease and disease services towards a focus on health and wellness, was inevitably a case of not far enough to some, but too far for others. Thus, on the one hand, Dorn and Laws (1994), drawing on disability studies and post-structuralist thought, noted Kearns’ lack of engagement with the literature on the body and the specificity of his cultural/humanistic theoretical position. On the other hand, Mayer and Meade (1994) and, to an extent, Paul (1994; 1995) were more concerned to identify a continuing relevance for medical geography’s disease ecology tradition. Looking back, it is possible to draw three lessons from the debate. First, Kearns’ ideas were notable for their specificity. They indicated one direction for development: a cultural geography of wellness. Second, Dorn and Laws (1994) remind us that, in terms of the then emerging post-structural turn in geography and the wider social sciences, health geography remained some way off from the (perceived) cutting edge of academic inquiry. This characterization was perhaps unjustified but it was indicative of a fundamental problem we return to later: the external image of health geography within the broader human geography community. Third, while it might be tempting to see the rebuttals of Mayer and Meade (1994) and Paul (1994) as indicative of conservatism within the subdiscipline, they also show that the need for change was far from a consensus view. Further, when the geographical location of Mayer and Meade (and Paul) is considered, there was an implication that, though there were subsequently to be exceptions (e.g., Brown and Colton, 2001; Craddock, 2000), the call for a new geography of health might be heeded less in the USA. Moreover, the research interest of two of the individuals concerned (Meade and Paul) in the intersection of development and health perhaps also anticipates an opposition grounded in the continuing relevance of disease ecology in less-developed settings. This in turn might be taken as a (somewhat simplistic) explanation for the relative lack of impact of any new health geography beyond what we can characterize as its Atlanto-Antipodean hearth.

    Our third set of developmental statements is provided by the introductory commentaries that have accompanied major conferences of health geographers (Bentham et al., 1991; Earickson, 1993; Hayes, 1996; Picheral, 1995; Matthews and Rosenberg, 1995; Matthews, 1995; Moon et al., 1998; Cummins and Milligan, 2000; Earickson, 2000a). Collectively, these statements assert that medical/health geography has changed in the recent past. The key observations are that there is an increased awareness that places matter, an enhanced sensitivity to difference (notably in confronting issues of gender and impairment), and a move away from the two traditions model in favour of more thematic concerns. These observations found a forum beyond established journals with the launch of Health and Place in 1995. The central concern of the new journal was studies ‘. . . where place matters with regard to health, health care and health policy’ (Moon, 1995: 1). Inevitably, with this remit, health geographers have figured significantly among contributors. In reviewing the contributions to the journal it is, however, evident that by no means all have engaged actively with what we have begun tentatively to associate with the new geography of health. Indeed, the initial editorial statement gave explicit encouragement to this pluralism by announcing an intention to publish high-quality papers employing more traditional approaches alongside a commitment to newer perspectives.

   Successive editions of The dictionary of human geography provide a final indicator of subdisciplinary change over the past decade. Of course, as with earlier sets of sentinel publications (and indeed our present review), entries in the Dictionary mirror the concerns and academic lineage of their authors and are inevitably partial rather than definitive accounts. None the less, the entries provide a useful window summarizing the changing nature of the research area. Thus, in the most recent edition (Johnston et al., 2000), the entries for medical geography and for the geography of health and health care both argue that changes have occurred recently and both emphasize the emergence of the theme of place (Mohan, 2000a; 2000b). In the entry for medical geography, there is a stress on a biomedical model of health and a focus on quantitative methods; place is framed as part of a critique. In contrast, the entry for health geography has place as the lead theme, Foucault gets a mention, there is an emphasis on what is termed a ‘socioecological’ model of health, and methodological pluralism rules. 

   Overall, it appears from the material we review above that visions for new geographies of health are centrally about the emerging importance of place in the study of health. Place has been seen as an operational ‘living’ construct which ‘matters’ as opposed to being a passive ‘container’ in which things are simply recorded. The development of a distinctive concern with health as opposed to disease was, in contrast, given less emphasis in positioning statements despite its key importance in the nomenclature underpinning the move from medical to health geography (Rosenberg, 1998). Alongside ‘place’ and ‘health’, there are also other discernible claims: that new geographies of health might take a more critical perspective; would probably be less likely to use quantitative methods; would draw strongly on developments elsewhere in geography and in other (social) sciences; and, as a consequence of the last point, would present more theorized perspectives, drawing particularly on cultural theory. We contend, therefore, that new geographies of health are, in part at least, medical geography’s cultural turn. As with experience of that contested term elsewhere in human geography, it was envisioned and evolved differentially. Diversity was inevitable. Rather than privileging the assumption that a genuinely new geography of health has actually emerged, we now proceed from outlining the objectives of the new geography of health, and noting critiques of these objectives, to considering the extent to which the objectives have been fulfilled. 


1 Place 

  An awareness of place as a socially constructed and complex phenomenon has been a talismanic point of reference for the new health geography. The objective has been to show that ‘places matter’ with regard to health, disease and health care, and it has been followed through in three strikingly different ways.
First, there has been a group of studies that are grounded in the specifics of particular localities. This group includes work on community responses to threats to health (e.g., Luginaah et al., 2000; Wakefield and Elliott, 2000) and studies of the place-specific aspects of health service restructuring (e.g., Barnett, 2000; Joseph and Chalmers, 1996; McLafferty and Tempalski, 1995). Much of this work has the ‘local place’, ranging from the home to urban and rural localities, as its focus. As a consequence, contemporary health geography exhibits a particular geography of places reflecting the location of health geographers and their research sites. The epistemological underpinnings of this quest to read place have varied with researchers drawing on positivist, politicaleconomic and humanist traditions. Arguably, eclectic deployments of the humanist tradition and its legacy of methodological perestroika have allowed the most nuanced and effective contributions. These, following Eyles (1985), have invoked consideration of the experience of both literal place and perceived place-in-the-world. The dynamic has demanded attentiveness to the voices of researched people and has been particularly effective at the interface with feminist and disability studies (Parr and Butler, 1999; Moss and Dyck, 1996; 1999). Yet, while the place-knowledges generated by this work may offer general lessons, they are also place-bound. Through the literature of health geography, we know much of Auckland, Ontario and Lancashire but little of neighbouring places.

  A second group of studies has considered the notion of ‘landscape’ and brought an enhanced awareness of the cultural importance of place and the intersection of the cultural and the politico-economic in the development of place-specific landscapes of health care and health promotion. From landscapes of despair (Dear and Wolch, 1987) through landscapes of restructuring (Barnett and Kearns, 1992) to therapeutic landscapes (Gesler, 1992; Williams, 1999), landscape has been an important motif in the development of the geography of health. By extension, it has also underpinned work including the geography of asylums as places of refuge (Parr and Philo, 1995). In these various guises the idea of ‘landscape’ has sought to convey many different meanings. For some, it is analogous to literally defined localities. For others it is a metaphor for the complex layerings of history, social structure and built environment that converge in particular places. Though its differing meanings suggest a degree of pluralism which sometimes borders on the chaotic, there is also a sense in which, notwithstanding its internal inconsistency, it remains the term that most clearly embodies the tropes of place and health that were expected to be the hallmarks of a new geography of health. Furthermore, although the use of place implied in ‘landscape’ studies may, in some ways, be a borrowed construct – most notably from Massey (1984) on the one hand and Cosgrove (1998) on the other – there is also a reasonable claim to terminological ‘ownership’. Thus, in the case of therapeutic landscapes, we actually have a metaphorical construct that was not only ‘invented’ for application to health geography but was also coined by a person working within the project to construct a new geography of health (Gesler, 1992). 

  A third set of works where explicit claims for place-awareness have been made is provided by the various studies employing multilevel modelling (e.g., Jones and Duncan, 1995; Duncan et al., 1996; 1998; 1999; Twigg et al., 2000; Congdon et al., 1997; Langford and Bentham, 1996; Verheij et al., 1999). Two points can be made here. First, the multilevel perspective has, to date in health geography, been mostly a UK (and Dutch) fascination. While this may simply reflect the mundane but important issue of access to suitably large data sets, it also points to an enduring quantitative research tradition based around the application of the generalized linear model to questions of health equality/inequality. Interestingly, work in health geography employing GIS and spatial analysis has typically followed a similar trajectory (e.g., Parker and Campbell, 1998; Wall and Devine, 2000; Schweikart and Kistemann, 2001; Sabel et al., 2000; Kim et al., 2000; Boyle et al., 1999; Gatrell and Bailey, 1996). Our second and more substantive point about the multilevel perspective involves its conceptualization of place. Here we find both strengths and weaknesses. On the positive side, multilevel perspectives give clear recognition to the idea of hierarchy and the nesting of people within places. They allow a ‘decomposition’ of variation to particular ‘levels’: the individual or the contextual. They also allow for considerable complexity in forms of contextual variation and are thus both more faithful to external reality and effective as an empirical means of ‘capturing place’. Yet in this empirical dimension lie difficulties. Multilevel models are a technical means to a theoretical end; the ‘place’ they capture is (merely) that of the higher-level measurement units employed in the particular model. These may have little sociological significance and tell us more about data-collection strategies than the realities of place effects. None the less, providing that cognizance is given to the inevitable limitations of quantitative analysis, multilevel models provide a clear example of another approach to place-sensitivity where a development within health geography (albeit one borrowed from educational statistics) has had an impact in other parts of the geographical discipline. 

   The three areas that we have identified are those where contributions have been made that self-locate within the new geography of health. Each is different. In the first, it is the place where the study is undertaken that is important. They are, in effect, locality studies. The extent to which place matters can vary, yet is often limited. The second category – ‘landscapes’ – comes closest to capturing the characteristics claimed for a new geography of health and has been influential in moving health geography from an overtly quantitative emphasis towards a position of methodological pluralism. Multilevel perspectives are perhaps best seen as being an effective but limited quantitative methodology for addressing questions of place. From a critical perspective, what we therefore have (with the possible exception of work on therapeutic landscapes and landscapes of mental health care) are new geographies of health that owe much to continuing traditions. Paradoxically, one perspective that has explicitly not associated itself with the new geography of health – disease ecology – is arguably both more literally place-aware and more theoretically consistent in its place awareness than either multilevel modelling or the locality studies.

   The evidence thus points to a situation where place, though undoubtedly a focal concept in the new geography of health, is neither unproblematic nor coherently applied. Furthermore, the degree to which it has been focal has varied nationally. In British health geography, for instance, it has been more of an implicit construct, with a distinction made between context and composition – an almost talismanic terminology that interestingly originated in sociology (McIntyre et al., 1993). There has been a tendency to reduce place to space and equate it to the ecological, the aggregate or, in multilevel terms, the level-two measuring units made available in government statistics and through the spatialized application of governance. In New Zealand, by contrast, there has been a clearer interaction between the ‘locality’ and the ‘landscape’ theme (Kearns, 1998). In Canada, until recently, the ‘locality’ theme has dominated, though the ‘landscape’ theme has now gained ground. Elsewhere, diversity has ruled and, if one prescription can be made, it is that there is a need for greater contextualization in health geographic research. In making this statement, we do not advocate a return to the idiographic. Rather, we suggest that there remains an important role for developing normative ideas through comparing places.

2 Theory

   It is relatively new for health geography to concern itself with theory. This statement is not to overlook the long-established application of ideas such as central place theory in spatial-analytic medical geography, nor is it to disregard the fact that, not so long ago, the term ‘theoretical’ effectively signified the quantitative and positivist (Bunge, 1966). Rather, it is to signal the novelty of not only applying, but also developing, a particular form of critical social theory: ‘. . . one that sees theoretical activity as a creative procedure that involves a qualitative jump beyond experiential evidence’ (Berg, 1994: 245). Thus, the newness of the ‘coming out’ into theoretical awareness by health geographers (Litva and Eyles, 1995) has to do with recognizing (at least implicitly) the social-theoretic context of health and of health-related subject matter. For example, in research on the landscapes of private medicine we actively participate in creating new understandings of ‘the consumer’, rather than simply adopting and testing explanations developed elsewhere and by others (Kearns and Barnett, 1997). 

   With respect to theory, medical geography has always been a ‘magpie discipline’, collecting what fits from elsewhere. If there is theoretical novelty in the ‘new health geography’, it will therefore be both borrowed and reshaped for specific application to health geographic research. This characterization could certainly be applied to work taking place on the interface between cultural and social geography, including research using the landscape metaphor (Moon and Brown, 2001; Gleeson and Kearns, 2001; Dorn, 1999) Variously using perspectives derived from interactionist sociology, illness behaviour studies, ethics, queer theory and Foucault, this work is diverse but typified by a post-positivist approach to theory that avoids seeking universal truths, but rather ‘. . . attempts to account for the position and partial perspective of the researcher’ (Berg, 1994: 246). 

   Alongside this borrowing, we can also discern omissions and continuities. With regard to omissions, a key gap in the corpus of health-geographic knowledge is the relative lack of engagement with the literature on the body (Longhurst, 1997). Health geography remains relatively disembodied, although recent writing by geographers working at the permeable edges of health and social geography is addressing this gap (see Dyck, 1995; Moss and Dyck, 1996; Parr, 1998; Litva et al., 2001; Hall, 2000), and others who might not identify with health geography have made valuable contributions (Valentine, 1999). The present situation is effectively one where recent work is ‘. . . increasingly engaging with the body as a site of medical inscription and resistance . . . crucially often in relation to place’ (Butler and Parr, 1999: 11). The recency of this development is strangely paradoxical in view of the omnipresence of the body in the cultural literatures that were purportedly one of the defining influences on the new geography of health. This absence was noted by Dorn and Laws (1994) as well as in the founding editorial in Health and Place (Moon, 1995). In general, people – in the sense of acknowledged, autonomous, sentient beings – remain generally absent from the narratives of health geography (but rather more present in the often reluctantly related field of disability geography) (e.g., Dyck, 1999; Moss, 1999). A tendency to see the individual not as a person but as an observation has been largely retained in health geography (although geographies of mental health have long-included exceptions – see Dear et al., 1980; Kearns, 1990; Parr, 1998). This neglect is not unusual for a research area with a medicalized heritage: the sociology of health and illness exhibits the same tendencies, though perhaps to a lesser extent, while the vast area of public health relegates bodily concerns to the distant dependency of critical public health. Nevertheless it might have been expected that a shift towards geographies of health would have been accompanied by a decrease in concern with dead and diseased bodies and greater interest in healthy bodies. Such work is, however, largely conducted outside health geography and, with exceptions (MacKian, 2000; Duncan and Brown, 2000; Smyth, 1998), the very specific consequences for health of body adornment, maintenance, inscription and management have not been discussed. 

   A second absence concerns the new public health and allied notions of risk. This is a partial absence in that constructs associated with the new public health underpin the growing geographical interest in population health (Dunn and Hayes, 2000; Hayes, 1999). Elliott et al. (1993) and Eyles et al. (1993) have explored notions of risk in environmental health and, a decade earlier, notions of risk provided an implicit underpinning to the work of the ‘McMaster School’ studies of the geography of mental health care (e.g., Dear and Taylor, 1982; see Philo, 1997, for a review and Moon, 2000, for a contemporary application). These are, however, limited applications in comparison to the nascent study potential. Health-related behaviour is just one area where risk provides an underlying construct that begs further theorization with regard to its spatialized manifestation. Looking out from health geography, it is also clear that much groundwork has been already undertaken in this regard in other disciplines. We cannot help but see startling geographical takes on the works of sociologists such as Bunton and Macdonald (1992), Bunton et al. (1995) and Peterson and Lupton (1996), yet these authors are seldom cited in academic health geography where citation patterns tend towards more traditional medicalized public health perspectives on risk rather than sociological approaches. 

   Turning now to continuities in health geography’s engagement with theory, perhaps ironically, given our foregoing discussion, we think that there remains a case for seeing positivism as a guiding theoretical principle for some health geography. Here we think of the continuing quest for law-like regularities that characterizes much health geography. Positivist perspectives might not be new, but their applications are often particularly well made in health geography. This claim is evidenced in work on placesensitivity using multilevel modelling as well as work on environment-health interactions (Bentham 1991; Gatrell and Bailey, 1996) and on epidemic modelling (Thomas, 1996; Smallman-Raynor et al., 1992; Smallman-Raynor and Cliff, 1999). It is also exemplified in the UK context by the impact of the Economic and Social Research Council (ESRC) programme of research on health variations, which has encouraged empirical if not necessarily positivist research. While these approaches may not readily be seen as theoretical in the same way as research employing sociocultural perspectives, the work is exemplary and highly innovative within the established and accepted canons of scientific method.

  A further theoretical continuity is provided by equality/inequality and its partner exclusion/inclusion. Certainly, if there are constructs that cross health and health care geographies, it is these. Again, the various projects running under the ESRC Health Variations Programme in Britain provide an illustration of such work; where these projects are theorized it is often by reference to ideas of equality or exclusion. Other examples include work by Scarpaci (1988; 1989), Smith (1990), Smith et al. (1997) and Barnett et al. (2000) on aspects of health policy. Central to such work is ‘explanation’. In his survey of health care geography, Mohan (1998) indicated something of the theoretical constructs lying beyond equality even within a relatively traditional frame of political economy. What should, however, be noted is that, in common with the rest of geography, the theories of equality and exclusion that have been deployed in health geography have emerged almost entirely from a perspective that might be called redistributionist or welfarist. Without for one moment denying the analytical capacity of this perspective, it is striking that the dominance of neoliberal agendas in national governance and specifically in health service policy has not resulted in studies arguing in favour of inequality. In short, though to oversimplify, geographies of health (in)equality have been resolutely of the left.
Arguably the key framework offering the capacity to link together the diverse theoretical perspectives currently deployed in health geography has been the structure and agency dynamic (Giddens, 1984; Wolch and Dear, 1989). This has the capacity to integrate people and places as well as the local and the global, and facilitates generalization outwards from microlevel case studies. With care, structure-agency can also be used to confront perhaps the key challenge facing future theorized health geographies: the incorporation of time. To confront this challenge, there is a need to move beyond snapshot studies of health in places towards repeated cross-sections and genuinely longitudinal studies. Though the terminology is quantitative, the methodology need not be. We tend to compare then and now and assume development, retrogression and evolution without assessing the sufficiency of research design. In this respect, a greater engagement with the process of change is warranted. 

3 From white coats to leather jackets: developing critical health geography 

. . . if critical social analysis is omitted from medical geography 
research, then spatially-based investigations will tend to accept and perpetuate the status quo and do little to remove inequalities. (Pacione, 1986: x) 

One mark of novelty in health geography is its emerging connection with a critical human geography defined by Painter (2000: 126) as:

. . . a rapidly changing set of ideas and practices within human geography linked by a shared commitment to emancipatory politics within and beyond the discipline, to the promotion of progressive social change and to the development of a broad range of critical theories and their application in geographical research and political practice

   In evaluating whether health geography has become critical, we must begin by noting that many geographers who see themselves as critical and who research health issues may not see themselves as health geographers. We can identify a number of key contributors to the trajectory of health geography over the last decade who have neither participated regularly in health geography meetings nor identified with the subdisciplinary label.1 This question of identification may ultimately be a matter of personal taste, but it also may have much to do with the persistence of a view of medical/health geography in which the reductionist spectres of a positivist geography of health care, spatial epidemiology and disease ecology loom large. These (mis)conceptions combine with the tenacity of the (presumed) links with clinical medicine to create an implication that health geography may be sometimes less than critical.

  Painter (2000) signals that critical geography involves opposition to unequal and oppressive power relations, commitment to social justice and transformative politics, and the development and application of critical theories. We will consider only the first two of these hallmarks, given that we have considered theory in the previous subsection. While traces of each are clearly evident in contemporary health geography, it is the first that is most strongly embedded, as we have already noted in our short discussion of theories of inequality. Earickson (2000b: 457) describes this approach as ‘timeless’: the inequities and oppressions have persisted, and so have the efforts by geographers to address them. Indeed, his survey of Social Science and Medicine and Health and Place revealed that 20% of papers published over the last 15 years dealt with inequity. Closely connected to this theme is the gradual shift in the construction of ‘the field’ for health geographers. In the roots of the research tradition, tropical disease ecology, the field was (and, for some, still is) a place that is there rather than here. A key shift among health geographers in this regard has been connected with feminist scholarship: the recognition that we are always and already in the field (Katz, 1994). Thus, recent cultural geographies of health have less frequently been outsider accounts of the exotic, and more often critical interpretations of the conditions of our own experience (e.g., Milligan, 2000).
 
   The second hallmark of critical geography is its commitment to social justice and transformative politics. To this extent, the health (care) implications of neoliberal policies have become a key object of research through the 1990s and this is well illustrated in the enduring (if not heightened) concerns for equity in health status and access to services (Earickson, 2000b), the gradients of health status (Hayes, 1999) and the reconstruction of patients as consumers (Kearns and Barnett, 1997). There is also an enduring tension between analysis and action. As Earickson (2000b: 457) wistfully notes: ‘. . . a presidential campaign and conflict in Vietnam were far more important’ (than his research on more equitable health and health care for minorities). On the one hand, perhaps as one reflects back on a graduate career, this poignant view is inevitable; many an ideal to change the world is tempered by the realization that the only world one really changes is one’s own. However, on the other hand, as critical health geography has taken root, a modest blend of activism and academic pursuit has emerged as a viable possibility. One emerging view suggests possibilities of supporting ‘. . . those political leaders with a moral commitment to public health’ (Greenberg et al., 1990: 176). While there are costs to such activism, such as a diminished identity within academic geography and loss of research time, the benefits include the satisfaction of seeing political as well as practical change and broadened networks beyond the academy. It may be that local-level activism can minimize such losses, but maximize the gains in terms of developing a social justice agenda and participating in transformative politics (Collins and Kearns, 2001). However, successful activism need not be at the microscale. This point is epitomized in the work of Shaw, Dorling and colleagues (e.g., Shaw et al., 1999) whose re-use of secondary data is effectively deployed in formulating antidotes to discourses of progress and development by national health services. 
Equally, activism and criticality can be achieved through teaching: students are a key audience. Most of us teach and are driven to some degree by passions for various and often contradictory notions like justice, rights, needs and responsibilities. The privilege of academic freedom allows teaching to be a form of activism (Hay, 2001). As geographers, we increasingly question the applicability of what we do and ask about its relevance (Scottish Geographical Journal, 1999). In partial answer to such angst, perhaps we should look no further than our own abilities to challenge students in a lecture theatre. We might not be able to change the world at large, but, if we influence students’ worlds, they in turn, and in time, may change ours (Kearns, 2001). On a mundane level, this applicability is evident in what we teach (issues like smoking and drinking have a certain intrinsic appeal to younger student audiences). It is also reflected in the appearance of journal issues on teaching medical geography (Matthews and Rosenberg, 1995) and the increasing use of health-related questions in pre-university public examinations. 
Yet perhaps we should be wary of what we might call ‘critical fundamentalism’. What should we think of work that may indirectly benefit ‘real’ people, but which is directly sponsored by the state? Health geographers often seek to influence those who make or interpret policy, or who plan for, or provide, health care services. Is it more effective to do this through insurgency or collaboration? The challenge, perhaps, is to seek out levers of change beyond the more obvious ones held by those in positions of power. Critical perspectives on cherished policies are not always welcome and there is a gulf between academia and the policy world that is more easily bridged as an insurgent microscale researcher than as a policy consultant. A further challenge is to ensure that, whether the work is policy-relevant ‘consultancy’ or politically correct critical academic geography, it is also robust basic or applied research. Much policy research and critical geography is routine application of tested methods or decontextualized reportage that contributes little to the sum of human knowledge. Thus, GIS research for health agencies may be extremely applied and highly relevant to policies to improve access to health care but far from the cutting edge of GIS research. Conversely, it may well be that critical research reveals a health policy to be unjust and discriminatory but, without posing alternatives, the sum benefit to humankind is nil.

  One defect of Painter’s (2000) assessment of critical geography is that it is very much a view from within geography, concerned with developments internal to the discipline. In medical/health geography this, while helpful to our foregoing discussions, also raises a key problem. For medical/health geography, criticality is inextricably bound up with the interface with medicine. In its early days, the then Medical Geography Study Group of the IBG co-opted a medically qualified representative to assist in building links with the medical profession (Phillips and Moon, 1992). These links have been sustained. However, the interest is no longer solely with medicine per se. Links with other disciplines demonstrating an interest in health are seen as equally important. In disciplinary terms, it is still probably specialists in public health medicine with whom most links occur, but there are also strong links with sociologists, policy analysts, statisticians and historians. What this means is that medicine now sits alongside other disciplines as an equal, not a superior, in terms of its continuing relevance to health geography.

  Two points of elaboration on the relationship of health geography to medicine are warranted in concluding this section. First, geographers tend to have a rather outdated vision of medicine. This is at least as problematic as the stereotypes that many health care professionals hold of us as demographers, mapmakers and spatial fetishists. The cutting edge of medicine has itself embraced health. We ignore medicine and medical power/knowledge at our peril, but we need to avoid setting up medicine as some sort of folk devil from which we are ‘progressively’ distancing ourselves. The biomedical may matter less than we once believed, but its influence cannot be completely denied. Nor is a social model of health necessarily something that has escaped the awareness of medicine entirely. Second, if the medical link was about establishing the relevance of medical geography, it may be that the process that has led to the emergence of health geography simply reflects wider changes. Medical hegemony has declined, but there are still constraints within which health geographers have to work. These can vary from access to research sites and research data to the privileging of certain research designs. Geographical studies do not rank highly in critical appraisals of the robustness of research evidence; qualitative studies are only now attracting a degree of respectability. Our point here is that critical geographies of illness and impairment (if not health itself) may be both based on outdated stereotypes of medicine and also, simultaneously, only of insular importance within geography. 

IV Discussion: what is new about the new geography of health?
 
   We have attempted to provide an assessment of the recent development of one area of human geography, and, in so doing, to suggest implications for the development of knowledge. To return to our theme of novelty, we can now ask: what are the constraints on innovation in health geography? We noted earlier that the results of neoliberal policy shifts in terms of health and health care have been of particular interest to geographers. As well as an object for geographical research, academics have been subject to neoliberalism policies. Increasingly competitive funding environments have, for instance, reconstructed the discourses of (health) research, and in turn constrained the achievement of ‘novelty’. Publications have increasingly become cast as ‘outputs’, a term replete with connotations of assembly-line productivity. Further, externally funded research projects have become essential to the overall financial health of geography departments. In this neoliberal landscape of research, particular constructions of ‘scientific’ method have been privileged over other types of scholarship – particularly in terms of funding in medically related areas – and funding itself has increasingly been directed rather than responsive (Berg and Roche, 1997). ‘Scientific’ explanations have tended to be discursively coded by funders as objective, truthful and hard, while narrative and interpretative approaches in health geography are (often at least implicitly) coded as subjective, untruthful and soft. These discursive codings have, we argue, led to a situation in which an empirical health variations project, for instance, is more ‘sellable’ than an investigation of therapeutic landscapes. The net result is that the latter type of work is more likely to be undertaken at cost to the researcher because it falls outside priority areas. 

   In these ways, the original ambitions for health geography that we reviewed earlier have been, to an extent, subverted by the neoliberal imperatives of academic life over the last decade. To generalize, this analysis provides at least a partial explanation for the strength of an acultural quantitative health geography in the UK (fuelled by the ESRC Health Variations Initiative), the persistence of a policy-led agenda in the USA and Canada, and, in the weaker funding environment of New Zealand, the relative strength of critical and cultural agendas. Furthermore, the very ‘proximity’ of health geography to the better-funded pastures of medical research has, perhaps, been one element in the increasing profile of health geography over the past decade of neoliberal restructuring. In competing, often successfully, for such resources, empirical health geography has grown at the expense of cultural, critical, theorized novelty. Although medical geography always had a strongly utilitarian orientation, this formalization of neoliberal priorities has had the paradoxical impact of raising the profile of the subdiscipline, yet inhibiting novelty and creativity, especially within the humanities part of the tradition.

   Looking outward to the parent discipline, do health concerns remain on the margins of geography? There are varying experiences of marginalization. One of us can recount a journal editor dismissing the relevance of his work because of a perceived limited interest in the national context of his research. The other had an encounter with an editor in which he was encouraged to publish in a specialist journal because health geography was not considered to have a wide enough appeal to the broad geographical constituency. The problem centres on the extent to which health geography is about geographies where health matters or health where geographies matter. In the final analysis, this distinction may amount to little but, in a disciplinary world, it suggests a tricky bind in which health is marginal to geography and geography is marginal to health. The answer to our question is thus probably ‘yes’ and, in the commitments made to interdisciplinarity shown in the material reviewed earlier, we perceive the response of health geography. Marginality within geography can be set against the impact to be gained by publishing in interdisciplinary and ‘other disciplinary’ outlets. We conclude that the ambitions for a new geography of health expressed in various publications we reviewed earlier have not brought about massive changes in the practice of health geography. Nevertheless, as recent texts signal (Gatrell, 2001; Gesler and Kearns, 2002), it is also clear that health geography has changed and at different rates, with accompanying geographies of change. Entries for both health geography and medical geography, in the latest edition of The dictionary of human geography (Johnston et al., 2000) would seem to underscore the fact that change has occurred. However, the points about rates of change and geographies of change are less well understood. We would argue that the rate of change has been faster than would have been expected under ‘normal’ conditions of subdisciplinary development. Thus, the number of published papers that have pursued themes of place, theory, criticality and, indeed, health has increased markedly over the past decade, albeit from a very low starting-point. Alongside this change, there has, however, also been a marked increase in the number of papers pursuing traditional medicalized themes – though we would link this development to the rise in publication outlets and collaborative research between geographers and medical scientists. We would also argue that new health geography has been characterized by geographically variegated practice. Novelty has, inevitably, been construed differently in different places and, though we risk gross generalizations, traditional medical geography has persisted more strongly in certain settings, notably the developing world and, to some extent, the USA.

  Together, these points might be taken to indicate the emergence of a duality within medical/health geography in which a ‘new’ is seeking ‘progressively’ to distance itself from an ‘old’. On the contrary, further investigation reveals that, alongside the reality of a gradual change, there are two processes in operation. First, and we have used the terminology already, there is a way in which the new geography of health has been a project in the cultural sense of the term. While some define themselves as within the project, others do not. The endeavours of all, however, contribute to the reinvention of the subdiscipline. Even those opposed to the tenets of the project, those effectively within the ‘old’ project of medical geography, benefit from the enhanced visibility that the articulation of the ‘new’ project brings. Through innovative developments in method (e.g., multilevel modelling) and theory (e.g., therapeutic landscapes), health/medical geography has metaphorically ‘put itself on the map’ within both geography and the wider health social sciences with regard to the understanding of place/health relations. Second, and as a partial consequence of the first process, we also find that there is no clear pattern of identification with the old and the new. Self-identification through deployment of the terms ‘health geography’ and ‘medical geography’ and synonyms in authorial abstracts over the past decade reveals individuals whom one might expect to be associated with the new assiduously describing their work as medical geography and vice versa. Furthermore, the focus of work in medical/health geography through the 1990s stuck resolutely, for the most part, to the study of disease and the care of the sick rather than an examination of wellness and health.

    Nor should we forget that novelty can produce marginalization. There needs to be space for difference. Without it, the forms of (new) health geography envisaged in the cultural revolution of year zero statements in the Professional Geographer or the appearance of a new journal (e.g., Health and Place) runs the risk of promoting a AtlantoAntipodean health geography orthodoxy in which there is an implicit ‘other’ of the ‘not-up-to-date’. Thus, there must, for instance, be a place for debate on forms of disease ecology where the stress is on chemistry and biology (Li et al., 1995; Foster and Zhang, 1995; Vasilevich, 1995). We are also reminded of journal submissions from ‘less developed countries’ sent to us to referee – submissions in which the paper is, in its own way, underdeveloped and weakened by poor English, lack of referencing and absence of theory. Yet such work can be replete with potential as well as local knowledge of place and commitment to change. In one sense, it is our loss that much of this work gets rejections from journals because it fails to meet ‘standards’ which ultimately are the standards of orthodoxy, our standards, or is published in journals that are closed to us through our own linguistic shortcomings. Ultimately, this situation is indicative of the marginalization of a range of ‘other’ (health) geographies that is the implicit and oftenneglected down side of the ‘project’ of ‘new’ health geography.

    It is tempting to conclude that, in the interests of collegiality, geographers concerned with health and medicine are simply retitling themselves without changing, hugely, the sort of work they do: a form of naming as norming (cf. Berg and Kearns, 1996). This conclusion would, however, be unjust. Concerns have changed. Today’s diversity of interests stands in stark contrast to earlier interests which were once almost exclusively concerned with disease ecology and, more latterly, with disease mapping and health care provision. This process of change has been, and is, evolutionary, with continuities sitting alongside the novelties in the ongoing project to reinvigorate geographical studies of health and health care. Globally, we can argue for the existence of a new geography of health that is now distinct from the established two traditions model of disease geography and health care geography. This development has led those interested in health (care) and medicine back into the heartland of geography while sustaining distinctive strengths.

Acknowledgements 

   This paper was originally drafted for a session at the RGS-IBG Annual Conference, 2000, at the University of Sussex. We thank participants at that meeting for their comments. Redrafts and restructurings were made while Graham Moon was a University of Auckland Foundation Visitor, then a Visiting Erskine Fellow at the University of Canterbury, Christchurch, New Zealand, and Robin Kearns was Visiting Professor at Queens University, Ontario. The authors acknowledge, gratefully, the support of these institutions.
 
Note 

1. Among such contributors might be Chris Philo and Michael Dear (e.g., Philo, 1996; 2000; Dear and Wolch, 1987) as well as researchers in elder care and the emerging field of disability studies (e.g., Laws and Radford, 1988). 


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