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Progress in Human Geography

DOI: 10.1191/0309132502ph389oa 2002; 26; 605 Prog Hum Geogr

Robin Kearns and Graham Moon change

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

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From medical to health geography:novelty, place and theory after adecade of changeRobin Kearns1* and Graham Moon21School of Geography and Environmental Science, The University of Auckland,Private Bag 92019, Auckland, New Zealand2Institute for the Geography of Health, University of Portsmouth, Mildam, BurnabyRoad, Portsmouth PO1 3AS, UK

Abstract: In this paper, we reflect on the positioning of health geography within the wideracademic landscapes of geography and health-related research. Drawing on examples from anumber of countries, we consider the extent to which a ‘new geography of health’ has emergedin recent years. We structure our discussion around the themes of place, theoretical engagementand critical relevancy. Changes within the subdiscipline are placed in the context of a centralquestion: 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 studentsand provide a focus for investment, while other themes go into decline. These changeshave long been recognized as central to the development of knowledge and scientificthought (Kuhn, 1962; Lakatos, 1970). In geography, the process has been signalled in thesuccessive editions of Geography and geographers (Johnston, 1997) and The dictionary ofhuman geography (Johnston et al., 2000). Thus, within the relatively recent past, the one-time ‘moribund backwater ’ of political geography has been reinvigorated (Painter,1995), there has been a reappraisal of regional geography (Sayer, 1989), culturalgeography has engaged with cultural studies and post-structuralism (Mitchell, 2000;

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

© Arnold 2002 10.1191/0309132502ph389oa

*Author for correspondence (e-mail: [email protected])



606 From medical to health geography

Jackson, 1993) and there has been editorial consideration of the ‘new economicgeography’ 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 majorchange, a break with a past and a new beginning. New developments have beencontrasted with past concerns and approaches, with accompanying implicationsregarding progress and the enhancement of knowledge.

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

We seek to interrogate the foregoing concerns through a survey of the contemporaryhistory of the geography of health. Our goal is to think through what is ‘new’ in the newhealth geography. Novelty has a number of connotations including something unusual,an innovation, a breakthrough and a fad. Here our analysis focuses on establishingdifference, on identifying a clear and marked change in the concerns of the subdisci-pline. We chart what is novel about health geography through the identification of threesalient themes: the emergence of ‘place’ as a framework for understanding health, theadoption of self-consciously sociocultural theoretical positions, and the quest todevelop critical geographies of health. We examine the extent to which these themeshave characterized research practice and draw conclusions that take account of thepolitical and practical context in which research practice has taken place. As a necessaryprelude to this examination, we begin with a brief review of the emergence of the newgeography of health, noting, in particular, the claims and ambitions articulated invarious programmatic statements as well as counterclaims, cautionary exhortations andsceptical critiques.

II Medical and health geographies

In this section, we trace the changes in scholarship that have led to the emergence of so-called ‘new health geographies’. Our argument is that, although programmaticstatements on potential new directions for a research area may have a paradigm-shifting ring about them, in reality social scientific research programmes seldom shiftrapidly or radically. As Martin (1999) noted with respect to the purported colonizationof geography by economics, although academic disciplines are predicated on the search



for novelty, the development of knowledge is seldom sudden. Evolution, rather thanrevolution, tends to be the case. The clarion calls of reformers, we suggest, speak withthe goal of catching attention and moving the middle ground of dominant discourses.Thus, contemporary health geography, if it is distinguished by novelty, will havechanged as a consequence of a collective, but contested, openness to the ideas of otherdisciplines as well as other constituent fields of geography. As we go on to discuss, oneissue here is the balance between change in health geography as a process developedfrom within the subdiscipline and the alternative possibility that any new healthgeography has simply mirrored, with some lag, developments elsewhere.

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

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

Through the 1990s, the purported transition from medical to health geography can becharted through reference to various key publications. The reports on medicalgeography in Progress in Human Geography; provide our first indicator of these shiftingconcerns. To date, these reports have tended to be deliberately framed as catalysts forchange, with reviewers eschewing the temptation of simply cataloguing recent publi-cations 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 thatthese essays often look outside health geography, and indeed outside geography itself,

Robin Kearns and Graham Moon 607




at areas in which health geography might frame knowledge or where such a framinghad already begun.

A second group of publications was, at least initially, more inward-looking. A paperby Kearns (1993) attempting to nudge the collective focus of medical geographytowards a cultural/humanistic standpoint through the advocacy of ‘post-medicalgeographies 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 diseaseand disease services towards a focus on health and wellness, was inevitably a case ofnot 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’ lackof engagement with the literature on the body and the specificity of hiscultural/humanistic theoretical position. On the other hand, Mayer and Meade (1994)and, to an extent, Paul (1994; 1995) were more concerned to identify a continuingrelevance for medical geography’s disease ecology tradition. Looking back, it ispossible to draw three lessons from the debate. First, Kearns’ ideas were notable fortheir specificity. They indicated one direction for development: a cultural geography ofwellness. Second, Dorn and Laws (1994) remind us that, in terms of the then emergingpost-structural turn in geography and the wider social sciences, health geographyremained some way off from the (perceived) cutting edge of academic inquiry. Thischaracterization was perhaps unjustified but it was indicative of a fundamentalproblem we return to later: the external image of health geography within the broaderhuman geography community. Third, while it might be tempting to see the rebuttals ofMayer and Meade (1994) and Paul (1994) as indicative of conservatism within the sub-discipline, 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 mightbe heeded less in the USA. Moreover, the research interest of two of the individualsconcerned (Meade and Paul) in the intersection of development and health perhaps alsoanticipates an opposition grounded in the continuing relevance of disease ecology inless-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 whatwe can characterize as its Atlanto-Antipodean hearth.

Our third set of developmental statements is provided by the introductory commen-taries 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 therecent past. The key observations are that there is an increased awareness that placesmatter, an enhanced sensitivity to difference (notably in confronting issues of genderand impairment), and a move away from the two traditions model in favour of morethematic concerns. These observations found a forum beyond established journals withthe launch of Health and Place in 1995. The central concern of the new journal wasstudies ‘. . . where place matters with regard to health, health care and health policy’(Moon, 1995: 1). Inevitably, with this remit, health geographers have figured signifi-cantly 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 editorialstatement gave explicit encouragement to this pluralism by announcing an intention topublish high-quality papers employing more traditional approaches alongside acommitment to newer perspectives.

Successive editions of The dictionary of human geography provide a final indicator ofsubdisciplinary change over the past decade. Of course, as with earlier sets of sentinelpublications (and indeed our present review), entries in the Dictionary mirror theconcerns and academic lineage of their authors and are inevitably partial rather thandefinitive accounts. None the less, the entries provide a useful window summarizingthe changing nature of the research area. Thus, in the most recent edition (Johnston etal., 2000), the entries for medical geography and for the geography of health and healthcare both argue that changes have occurred recently and both emphasize the emergenceof the theme of place (Mohan, 2000a; 2000b). In the entry for medical geography, thereis a stress on a biomedical model of health and a focus on quantitative methods; placeis framed as part of a critique. In contrast, the entry for health geography has place asthe 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 newgeographies of health are centrally about the emerging importance of place in the studyof health. Place has been seen as an operational ‘living’ construct which ‘matters’ asopposed to being a passive ‘container’ in which things are simply recorded. Thedevelopment 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 nomen-clature underpinning the move from medical to health geography (Rosenberg, 1998).Alongside ‘place’ and ‘health’, there are also other discernible claims: that newgeographies of health might take a more critical perspective; would probably be lesslikely to use quantitative methods; would draw strongly on developments elsewhere ingeography and in other (social) sciences; and, as a consequence of the last point, wouldpresent more theorized perspectives, drawing particularly on cultural theory. Wecontend, therefore, that new geographies of health are, in part at least, medicalgeography’s cultural turn. As with experience of that contested term elsewhere inhuman geography, it was envisioned and evolved differentially. Diversity wasinevitable. Rather than privileging the assumption that a genuinely new geography ofhealth has actually emerged, we now proceed from outlining the objectives of the newgeography of health, and noting critiques of these objectives, to considering the extentto which the objectives have been fulfilled.

III The themes they are a-changin’

In this section, we examine three themes, prefigured in the earlier discussion, that webelieve to be key characteristics of current health geography. First, we consider con-structions of place. This selection reflects distinctions drawn between medicalgeography’s traditional employment of the spatial as an unproblematized activity-container and alternative perspectives emphasizing constructed meanings and theexperiential aspects of place (Moon, 1990; Kearns and Joseph, 1993). Our secondthematic is the utility of sociocultural theory. This was an issue in The Professional





Geographer debate (Dorn and Laws, 1994; Kearns, 1994) and has remained an ongoingmatter of concern, notably with regard to perceptions of the relative poverty oftheoretical engagement in the geography of health (Litva and Eyles, 1995; Philo, 1996;Mohan, 1998). Third, we consider the case for a critical geography of health. With a textsubtitled (at least on the inside page) as ‘a critical medical geography’ (Jones and Moon,1987), it is possible to argue that the geography of health anticipated the current voguefor critical geography by some 10 years. Beyond revisionist history, however, this lasttheme allows us to raise matters related to the shift in subject focus implied in renamingmedical geography as the geography of health. Additionally, it permits us to considerthe consequences of conducting research in the shadow of the power of the medicalprofession and the political importance of health policy. In addressing these threethemes, we have drawn widely on research published during the past decade that hasexplicitly or implicitly located itself within medical/health geography.

1 Place

An awareness of place as a socially constructed and complex phenomenon has been atalismanic point of reference for the new health geography. The objective has been toshow that ‘places matter’ with regard to health, disease and health care, and it has beenfollowed through in three strikingly different ways.

First, there has been a group of studies that are grounded in the specifics of particularlocalities. 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-specificaspects 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 fromthe home to urban and rural localities, as its focus. As a consequence, contemporaryhealth geography exhibits a particular geography of places reflecting the location ofhealth geographers and their research sites. The epistemological underpinnings of thisquest to read place have varied with researchers drawing on positivist, political-economic and humanist traditions. Arguably, eclectic deployments of the humanisttradition and its legacy of methodological perestroika have allowed the most nuancedand effective contributions. These, following Eyles (1985), have invoked considerationof the experience of both literal place and perceived place-in-the-world. The dynamichas demanded attentiveness to the voices of researched people and has been particu-larly 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 workmay offer general lessons, they are also place-bound. Through the literature of healthgeography, we know much of Auckland, Ontario and Lancashire but little of neigh-bouring places.

A second group of studies has considered the notion of ‘landscape’ and brought anenhanced awareness of the cultural importance of place and the intersection of thecultural and the politico-economic in the development of place-specific landscapes ofhealth care and health promotion. From landscapes of despair (Dear and Wolch, 1987)through landscapes of restructuring (Barnett and Kearns, 1992) to therapeuticlandscapes (Gesler, 1992; Williams, 1999), landscape has been an important motif in thedevelopment 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 thesevarious 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 thecomplex layerings of history, social structure and built environment that converge inparticular places. Though its differing meanings suggest a degree of pluralism whichsometimes borders on the chaotic, there is also a sense in which, notwithstanding itsinternal inconsistency, it remains the term that most clearly embodies the tropes of placeand 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 someways, be a borrowed construct – most notably from Massey (1984) on the one hand andCosgrove (1998) on the other – there is also a reasonable claim to terminological‘ownership’. Thus, in the case of therapeutic landscapes, we actually have a metaphor-ical construct that was not only ‘invented’ for application to health geography but wasalso coined by a person working within the project to construct a new geography ofhealth (Gesler, 1992).

A third set of works where explicit claims for place-awareness have been made isprovided by the various studies employing multilevel modelling (e.g., Jones andDuncan, 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 (andDutch) fascination. While this may simply reflect the mundane but important issue ofaccess to suitably large data sets, it also points to an enduring quantitative researchtradition based around the application of the generalized linear model to questions ofhealth equality/inequality. Interestingly, work in health geography employing GIS andspatial 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 etal., 2000; Boyle et al., 1999; Gatrell and Bailey, 1996). Our second and more substantivepoint about the multilevel perspective involves its conceptualization of place. Here wefind both strengths and weaknesses. On the positive side, multilevel perspectives giveclear recognition to the idea of hierarchy and the nesting of people within places. Theyallow a ‘decomposition’ of variation to particular ‘levels’: the individual or thecontextual. They also allow for considerable complexity in forms of contextual variationand are thus both more faithful to external reality and effective as an empirical meansof ‘capturing place’. Yet in this empirical dimension lie difficulties. Multilevel modelsare a technical means to a theoretical end; the ‘place’ they capture is (merely) that of thehigher-level measurement units employed in the particular model. These may havelittle sociological significance and tell us more about data-collection strategies than therealities of place effects. None the less, providing that cognizance is given to theinevitable limitations of quantitative analysis, multilevel models provide a clearexample of another approach to place-sensitivity where a development within healthgeography (albeit one borrowed from educational statistics) has had an impact in otherparts of the geographical discipline.

The three areas that we have identified are those where contributions have beenmade 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. Thesecond category – ‘landscapes’ – comes closest to capturing the characteristics claimed





for a new geography of health and has been influential in moving health geographyfrom an overtly quantitative emphasis towards a position of methodological pluralism.Multilevel perspectives are perhaps best seen as being an effective but limited quanti-tative methodology for addressing questions of place. From a critical perspective, whatwe therefore have (with the possible exception of work on therapeutic landscapes andlandscapes of mental health care) are new geographies of health that owe much tocontinuing traditions. Paradoxically, one perspective that has explicitly not associateditself with the new geography of health – disease ecology – is arguably both moreliterally place-aware and more theoretically consistent in its place awareness than eithermultilevel modelling or the locality studies.

The evidence thus points to a situation where place, though undoubtedly a focalconcept in the new geography of health, is neither unproblematic nor coherentlyapplied. Furthermore, the degree to which it has been focal has varied nationally. InBritish health geography, for instance, it has been more of an implicit construct, with adistinction made between context and composition – an almost talismanic terminologythat interestingly originated in sociology (McIntyre et al., 1993). There has been atendency to reduce place to space and equate it to the ecological, the aggregate or, inmultilevel terms, the level-two measuring units made available in government statisticsand 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 oneprescription can be made, it is that there is a need for greater contextualization in healthgeographic research. In making this statement, we do not advocate a return to theidiographic. Rather, we suggest that there remains an important role for developingnormative ideas through comparing places.

2 Theory

It is relatively new for health geography to concern itself with theory. This statement isnot to overlook the long-established application of ideas such as central place theory inspatial-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 particularform of critical social theory: ‘. . . one that sees theoretical activity as a creativeprocedure that involves a qualitative jump beyond experiential evidence’ (Berg, 1994:245). Thus, the newness of the ‘coming out’ into theoretical awareness by healthgeographers (Litva and Eyles, 1995) has to do with recognizing (at least implicitly) thesocial-theoretic context of health and of health-related subject matter. For example, inresearch on the landscapes of private medicine we actively participate in creating newunderstandings of ‘the consumer’, rather than simply adopting and testing explana-tions 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 healthgeography’, it will therefore be both borrowed and reshaped for specific application tohealth geographic research. This characterization could certainly be applied to work



taking place on the interface between cultural and social geography, including researchusing the landscape metaphor (Moon and Brown, 2001; Gleeson and Kearns, 2001;Dorn, 1999) Variously using perspectives derived from interactionist sociology, illnessbehaviour studies, ethics, queer theory and Foucault, this work is diverse but typifiedby 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. Withregard to omissions, a key gap in the corpus of health-geographic knowledge is therelative lack of engagement with the literature on the body (Longhurst, 1997). Healthgeography remains relatively disembodied, although recent writing by geographersworking 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), andothers who might not identify with health geography have made valuable contribu-tions (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 thisdevelopment is strangely paradoxical in view of the omnipresence of the body in thecultural literatures that were purportedly one of the defining influences on the newgeography of health. This absence was noted by Dorn and Laws (1994) as well as in thefounding editorial in Health and Place (Moon, 1995). In general, people – in the sense ofacknowledged, autonomous, sentient beings – remain generally absent from thenarratives of health geography (but rather more present in the often reluctantly relatedfield of disability geography) (e.g., Dyck, 1999; Moss, 1999). A tendency to see theindividual not as a person but as an observation has been largely retained in healthgeography (although geographies of mental health have long-included exceptions – seeDear et al., 1980; Kearns, 1990; Parr, 1998). This neglect is not unusual for a research areawith a medicalized heritage: the sociology of health and illness exhibits the sametendencies, though perhaps to a lesser extent, while the vast area of public healthrelegates bodily concerns to the distant dependency of critical public health.Nevertheless it might have been expected that a shift towards geographies of healthwould have been accompanied by a decrease in concern with dead and diseased bodiesand greater interest in healthy bodies. Such work is, however, largely conductedoutside 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 apartial absence in that constructs associated with the new public health underpin thegrowing 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 envi-ronmental health and, a decade earlier, notions of risk provided an implicit underpin-ning to the work of the ‘McMaster School’ studies of the geography of mental healthcare (e.g., Dear and Taylor, 1982; see Philo, 1997, for a review and Moon, 2000, for a con-temporary application). These are, however, limited applications in comparison to thenascent study potential. Health-related behaviour is just one area where risk providesan underlying construct that begs further theorization with regard to its spatializedmanifestation. Looking out from health geography, it is also clear that much





groundwork has been already undertaken in this regard in other disciplines. We cannothelp but see startling geographical takes on the works of sociologists such as Buntonand Macdonald (1992), Bunton et al. (1995) and Peterson and Lupton (1996), yet theseauthors are seldom cited in academic health geography where citation patterns tendtowards more traditional medicalized public health perspectives on risk rather thansociological approaches.

Turning now to continuities in health geography’s engagement with theory, perhapsironically, given our foregoing discussion, we think that there remains a case for seeingpositivism as a guiding theoretical principle for some health geography. Here we thinkof the continuing quest for law-like regularities that characterizes much healthgeography. Positivist perspectives might not be new, but their applications are oftenparticularly well made in health geography. This claim is evidenced in work on place-sensitivity using multilevel modelling as well as work on environment-health interac-tions (Bentham 1991; Gatrell and Bailey, 1996) and on epidemic modelling (Thomas,1996; Smallman-Raynor et al., 1992; Smallman-Raynor and Cliff, 1999). It is alsoexemplified in the UK context by the impact of the Economic and Social ResearchCouncil (ESRC) programme of research on health variations, which has encouragedempirical if not necessarily positivist research. While these approaches may not readilybe seen as theoretical in the same way as research employing sociocultural perspectives,the work is exemplary and highly innovative within the established and acceptedcanons of scientific method.

A further theoretical continuity is provided by equality/inequality and its partnerexclusion/inclusion. Certainly, if there are constructs that cross health and health caregeographies, it is these. Again, the various projects running under the ESRC HealthVariations Programme in Britain provide an illustration of such work; where theseprojects are theorized it is often by reference to ideas of equality or exclusion. Otherexamples include work by Scarpaci (1988; 1989), Smith (1990), Smith et al. (1997) andBarnett et al. (2000) on aspects of health policy. Central to such work is ‘explanation’. Inhis survey of health care geography, Mohan (1998) indicated something of thetheoretical constructs lying beyond equality even within a relatively traditional frameof political economy. What should, however, be noted is that, in common with the restof geography, the theories of equality and exclusion that have been deployed in healthgeography have emerged almost entirely from a perspective that might be called redis-tributionist or welfarist. Without for one moment denying the analytical capacity of thisperspective, it is striking that the dominance of neoliberal agendas in nationalgovernance and specifically in health service policy has not resulted in studies arguingin 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 diversetheoretical perspectives currently deployed in health geography has been the structureand agency dynamic (Giddens, 1984; Wolch and Dear, 1989). This has the capacity tointegrate people and places as well as the local and the global, and facilitates general-ization outwards from microlevel case studies. With care, structure-agency can also beused 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 beyondsnapshot studies of health in places towards repeated cross-sections and genuinely lon-gitudinal studies. Though the terminology is quantitative, the methodology need not




be. We tend to compare then and now and assume development, retrogression andevolution without assessing the sufficiency of research design. In this respect, a greaterengagement 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 willtend 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 criticalhuman geography defined by Painter (2000: 126) as:

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

In evaluating whether health geography has become critical, we must begin by notingthat many geographers who see themselves as critical and who research health issuesmay not see themselves as health geographers. We can identify a number of key con-tributors to the trajectory of health geography over the last decade who have neitherparticipated regularly in health geography meetings nor identified with the subdisci-plinary label.1 This question of identification may ultimately be a matter of personaltaste, but it also may have much to do with the persistence of a view of medical/healthgeography in which the reductionist spectres of a positivist geography of health care,spatial epidemiology and disease ecology loom large. These (mis)conceptions combinewith the tenacity of the (presumed) links with clinical medicine to create an implicationthat health geography may be sometimes less than critical.

Painter (2000) signals that critical geography involves opposition to unequal andoppressive power relations, commitment to social justice and transformative politics,and the development and application of critical theories. We will consider only the firsttwo of these hallmarks, given that we have considered theory in the previoussubsection. 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 shortdiscussion of theories of inequality. Earickson (2000b: 457) describes this approach as‘timeless’: the inequities and oppressions have persisted, and so have the efforts bygeographers to address them. Indeed, his survey of Social Science and Medicine andHealth and Place revealed that 20% of papers published over the last 15 years dealt withinequity. Closely connected to this theme is the gradual shift in the construction of ‘thefield’ for health geographers. In the roots of the research tradition, tropical diseaseecology, the field was (and, for some, still is) a place that is there rather than here. A keyshift among health geographers in this regard has been connected with feministscholarship: the recognition that we are always and already in the field (Katz, 1994).Thus, recent cultural geographies of health have less frequently been outsider accountsof the exotic, and more often critical interpretations of the conditions of our ownexperience (e.g., Milligan, 2000).

The second hallmark of critical geography is its commitment to social justice andtransformative politics. To this extent, the health (care) implications of neoliberal




policies have become a key object of research through the 1990s and this is wellillustrated in the enduring (if not heightened) concerns for equity in health status andaccess to services (Earickson, 2000b), the gradients of health status (Hayes, 1999) andthe reconstruction of patients as consumers (Kearns and Barnett, 1997). There is also anenduring tension between analysis and action. As Earickson (2000b: 457) wistfullynotes: ‘. . . 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 onehand, 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 worldone really changes is one’s own. However, on the other hand, as critical healthgeography has taken root, a modest blend of activism and academic pursuit hasemerged 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 withinacademic geography and loss of research time, the benefits include the satisfaction ofseeing political as well as practical change and broadened networks beyond theacademy. It may be that local-level activism can minimize such losses, but maximize thegains in terms of developing a social justice agenda and participating in transformativepolitics (Collins and Kearns, 2001). However, successful activism need not be at themicroscale. 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 formulatingantidotes to discourses of progress and development by national health services.

Equally, activism and criticality can be achieved through teaching: students are a keyaudience. Most of us teach and are driven to some degree by passions for various andoften contradictory notions like justice, rights, needs and responsibilities. The privilegeof academic freedom allows teaching to be a form of activism (Hay, 2001). Asgeographers, we increasingly question the applicability of what we do and ask about itsrelevance (Scottish Geographical Journal, 1999). In partial answer to such angst, perhapswe should look no further than our own abilities to challenge students in a lecturetheatre. 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 acertain intrinsic appeal to younger student audiences). It is also reflected in theappearance of journal issues on teaching medical geography (Matthews and Rosenberg,1995) and the increasing use of health-related questions in pre-university public exam-inations.

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 isdirectly sponsored by the state? Health geographers often seek to influence those whomake or interpret policy, or who plan for, or provide, health care services. Is it moreeffective to do this through insurgency or collaboration? The challenge, perhaps, is toseek out levers of change beyond the more obvious ones held by those in positions ofpower. Critical perspectives on cherished policies are not always welcome and there isa gulf between academia and the policy world that is more easily bridged as aninsurgent microscale researcher than as a policy consultant. A further challenge is toensure that, whether the work is policy-relevant ‘consultancy’ or politically correctcritical academic geography, it is also robust basic or applied research. Much policy




research and critical geography is routine application of tested methods or decontextu-alized reportage that contributes little to the sum of human knowledge. Thus, GISresearch for health agencies may be extremely applied and highly relevant to policies toimprove 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 discrimina-tory 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 mucha view from within geography, concerned with developments internal to the discipline.In medical/health geography this, while helpful to our foregoing discussions, alsoraises a key problem. For medical/health geography, criticality is inextricably bound upwith the interface with medicine. In its early days, the then Medical Geography StudyGroup of the IBG co-opted a medically qualified representative to assist in buildinglinks with the medical profession (Phillips and Moon, 1992). These links have beensustained. However, the interest is no longer solely with medicine per se. Links withother disciplines demonstrating an interest in health are seen as equally important. Indisciplinary terms, it is still probably specialists in public health medicine with whommost links occur, but there are also strong links with sociologists, policy analysts, sta-tisticians and historians. What this means is that medicine now sits alongside otherdisciplines as an equal, not a superior, in terms of its continuing relevance to healthgeography.

Two points of elaboration on the relationship of health geography to medicine arewarranted in concluding this section. First, geographers tend to have a rather outdatedvision of medicine. This is at least as problematic as the stereotypes that many healthcare professionals hold of us as demographers, mapmakers and spatial fetishists. Thecutting edge of medicine has itself embraced health. We ignore medicine and medicalpower/knowledge at our peril, but we need to avoid setting up medicine as some sortof folk devil from which we are ‘progressively’ distancing ourselves. The biomedicalmay 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 ofmedicine entirely. Second, if the medical link was about establishing the relevance ofmedical geography, it may be that the process that has led to the emergence of healthgeography simply reflects wider changes. Medical hegemony has declined, but thereare still constraints within which health geographers have to work. These can vary fromaccess 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 ofresearch 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, onlyof 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 ofhuman geography, and, in so doing, to suggest implications for the development ofknowledge. To return to our theme of novelty, we can now ask: what are the constraintson 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 neoliber-alism policies. Increasingly competitive funding environments have, for instance,reconstructed the discourses of (health) research, and in turn constrained theachievement of ‘novelty’. Publications have increasingly become cast as ‘outputs’, aterm replete with connotations of assembly-line productivity. Further, externallyfunded research projects have become essential to the overall financial health ofgeography departments. In this neoliberal landscape of research, particular construc-tions of ‘scientific’ method have been privileged over other types of scholarship – par-ticularly in terms of funding in medically related areas – and funding itself has increas-ingly been directed rather than responsive (Berg and Roche, 1997). ‘Scientific’ explana-tions have tended to be discursively coded by funders as objective, truthful and hard,while narrative and interpretative approaches in health geography are (often at leastimplicitly) coded as subjective, untruthful and soft. These discursive codings have, weargue, led to a situation in which an empirical health variations project, for instance, ismore ‘sellable’ than an investigation of therapeutic landscapes. The net result is that thelatter type of work is more likely to be undertaken at cost to the researcher because itfalls outside priority areas.

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

Looking outward to the parent discipline, do health concerns remain on the marginsof geography? There are varying experiences of marginalization. One of us can recounta journal editor dismissing the relevance of his work because of a perceived limitedinterest in the national context of his research. The other had an encounter with aneditor in which he was encouraged to publish in a specialist journal because healthgeography was not considered to have a wide enough appeal to the broad geographi-cal constituency. The problem centres on the extent to which health geography is aboutgeographies where health matters or health where geographies matter. In the finalanalysis, this distinction may amount to little but, in a disciplinary world, it suggests atricky bind in which health is marginal to geography and geography is marginal tohealth. The answer to our question is thus probably ‘yes’ and, in the commitmentsmade to interdisciplinarity shown in the material reviewed earlier, we perceive theresponse of health geography. Marginality within geography can be set against theimpact 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 thepractice of health geography. Nevertheless, as recent texts signal (Gatrell, 2001; Geslerand Kearns, 2002), it is also clear that health geography has changed and at differentrates, with accompanying geographies of change. Entries for both health geographyand 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 wellunderstood. We would argue that the rate of change has been faster than would havebeen expected under ‘normal’ conditions of subdisciplinary development. Thus, thenumber 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 lowstarting-point. Alongside this change, there has, however, also been a marked increasein the number of papers pursuing traditional medicalized themes – though we wouldlink this development to the rise in publication outlets and collaborative researchbetween geographers and medical scientists. We would also argue that new healthgeography has been characterized by geographically variegated practice. Novelty has,inevitably, been construed differently in different places and, though we risk gross gen-eralizations, traditional medical geography has persisted more strongly in certainsettings, notably the developing world and, to some extent, the USA.

Together, these points might be taken to indicate the emergence of a duality withinmedical/health geography in which a ‘new’ is seeking ‘progressively’ to distance itselffrom an ‘old’. On the contrary, further investigation reveals that, alongside the reality ofa gradual change, there are two processes in operation. First, and we have used theterminology already, there is a way in which the new geography of health has been aproject in the cultural sense of the term. While some define themselves as within theproject, others do not. The endeavours of all, however, contribute to the reinvention ofthe subdiscipline. Even those opposed to the tenets of the project, those effectivelywithin the ‘old’ project of medical geography, benefit from the enhanced visibility thatthe articulation of the ‘new’ project brings. Through innovative developments inmethod (e.g., multilevel modelling) and theory (e.g., therapeutic landscapes),health/medical geography has metaphorically ‘put itself on the map’ within bothgeography and the wider health social sciences with regard to the understanding ofplace/health relations. Second, and as a partial consequence of the first process, we alsofind that there is no clear pattern of identification with the old and the new. Self-identi-fication through deployment of the terms ‘health geography’ and ‘medical geography’and synonyms in authorial abstracts over the past decade reveals individuals whomone might expect to be associated with the new assiduously describing their work asmedical geography and vice versa. Furthermore, the focus of work in medical/healthgeography through the 1990s stuck resolutely, for the most part, to the study of diseaseand 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 bespace for difference. Without it, the forms of (new) health geography envisaged in thecultural revolution of year zero statements in the Professional Geographer or theappearance of a new journal (e.g., Health and Place) runs the risk of promoting a Atlanto-Antipodean 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 ofdisease 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 ‘lessdeveloped countries’ sent to us to referee – submissions in which the paper is, in its ownway, underdeveloped and weakened by poor English, lack of referencing and absenceof theory. Yet such work can be replete with potential as well as local knowledge ofplace and commitment to change. In one sense, it is our loss that much of this work getsrejections from journals because it fails to meet ‘standards’ which ultimately are thestandards of orthodoxy, our standards, or is published in journals that are closed to usthrough our own linguistic shortcomings. Ultimately, this situation is indicative of themarginalization of a range of ‘other’ (health) geographies that is the implicit and often-neglected down side of the ‘project’ of ‘new’ health geography.

It is tempting to conclude that, in the interests of collegiality, geographers concernedwith health and medicine are simply retitling themselves without changing, hugely, thesort of work they do: a form of naming as norming (cf. Berg and Kearns, 1996). Thisconclusion would, however, be unjust. Concerns have changed. Today’s diversity ofinterests stands in stark contrast to earlier interests which were once almost exclusivelyconcerned with disease ecology and, more latterly, with disease mapping and healthcare provision. This process of change has been, and is, evolutionary, with continuitiessitting alongside the novelties in the ongoing project to reinvigorate geographicalstudies of health and health care. Globally, we can argue for the existence of a newgeography of health that is now distinct from the established two traditions model ofdisease geography and health care geography. This development has led thoseinterested in health (care) and medicine back into the heartland of geography whilesustaining 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 theircomments. Redrafts and restructurings were made while Graham Moon was aUniversity of Auckland Foundation Visitor, then a Visiting Erskine Fellow at theUniversity of Canterbury, Christchurch, New Zealand, and Robin Kearns was VisitingProfessor at Queens University, Ontario. The authors acknowledge, gratefully, thesupport of these institutions.

Note

1. Among such contributors might be Chris Philo and Michael Dear (e.g., Philo, 1996; 2000; Dearand 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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