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health and health care, geography of

  A sub-discipline focused on the dynamic, and recursive, relationship between health, health services, and place, and on the impact of both health services and the health of population groups on the vitality of places. In brief, geographies of health and health care must go beyond description and cartography to construct accounts of why place matters to health and health care.

This focus is of a relatively recent origin (e.g. Kearns, 1993) and its development reflects a critique of the extent to which conventional medical geography adopted a biomedical model of disease. Critics argue that a socio-ecological model is needed to replace biomedicine. From such a perspective, analysis focuses on an interactive set of relationships between a population and its social, cultural and physical environment. This contrasts with the linear and unidirectional relationships implied by a biomedical model, with its emphasis on the monocausal origins of disease. Geographies of health thus (implicitly at least) take as their point of departure the World Health Organization\'s (WHO) emphasis on health as a \'state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity\'.

This move away from medical geography has had important analytical consequences for geographies of both health and health care. Crucially, there has been recognition of the importance of supplementing extensive, quantitative methods with intensive, qualitative investigations. The former are methodologically limited, it is suggested, because they cannot distinguish contextual effects (the difference a place makes) from compositional effects (what is in a place). Successful accounts of relationships between place and health therefore need to blend extensive and intensive approaches. Secondly, there is a new sensitivity to the body. Medical geography\'s understandings of health and illness have been restricted by defining bodies as sites \'invaded by a disease with a specific aetiology\' (Dorn and Laws, 1994). By contrast, recent work suggests that the body is a social construct. Given this view of health and well-being, the deviant body is no longer the product of medical diagnoses, nor does it necessarily require medical intervention (Dyck, 1995). Recent work on disability exemplifies this. Golledge (1996) argues for the application of traditional geographic skills to enable those with disabilities to navigate their environments safely and overcome physical constraints. Critics of this position suggest that it links the negative experiences of disabled people to individual impairment, rather than resulting from forms of social and political discrimination (Imrie, 1996); however, Golledge suggests that this is a utopian position which will yield little practical improvement in the lives of the disabled.

A third implication for geographies of health is a rather different conception of the subject. In biomedical models, people are simply seen as patients or as hosts to a disease. By contrast geographies of health and health care seek to foreground individuals\' subjective experiences, using participatory methods to engage respondents in the process of research (Kearns, 1994); showing how they contest and renegotiate socio-spatial constraints on their daily lives (Dorn and Laws, 1994). This offers scope to redeem medical geography from its genderless and colour-blind past (Mohan, 1989; Matthews, 1993). Studies have shown how social constraints, imposed by gender roles, are far more restrictive than spatial constraints, in terms of permitting women to access services. Likewise, lay perceptions of health and illness, and of what enables or constraints healthy lifestyles, should be given more prominence; such beliefs and attitudes are rooted in the characteristics of particular places (a pioneering study was Cornwell, 1984). Such issues have come to the fore in analyses of perceptions of the extent to which environmental hazards pose challenges to health, and in work which examines the political construction of healthy and unhealthy environments.

There are also signs of an emerging concern with a wider range of health services. When studied by geographers health care has often been taken to mean either primary care services (to a large degree, the location of general practitioners or family doctors) or hospital care. There have been studies of trends in the spatial organization of health care under a range of social systems and in recent years attention has been devoted to evaluating the geographical consequences of various health service reforms, for example in the former Soviet Union (Curtis and Taket, 1995). But there is recognition of the multifaceted nature of services and of the ways individuals and communities can draw upon a range of services, both formal and informal (Pinch, 1997). As a result, and in the spirit of what social-policy commentators characterize as welfare pluralism, there are increasing numbers of studies of informal and community-based sources of care, and of the interactions between the formal health-care system and alternative therapies. In addition, the role of self-help groups and of initiatives in the voluntary sector is receiving attention (e.g. Brown, 1995).

In this reformed geography of health and health care, there are signs of renewed sensitivity to place. There is acknowledgement, for example, of the therapeutic character of certain places (Gesler, 1992) in contrast to the socially dysfunctional characteristics of others (Wallace, 1990). The extent or otherwise of social capital — dense, informal networks of participation and sociability — can make a significant difference to the extent of social inequalities in health status (Wilkinson, 1996; Gatrell, 1997). There are also accounts of geographies of welfare services which demonstrate the significance of place to collective mobilization to defend or extend healthcare facilities. These are showing how social movements develop around health-care issues and how these contribute to a wider sense of participatory democracy and social cohesion (e.g. Scarpaci, 1991): by raising political consciousness and building new forms of oppositional political movements. Health care is a vehicle for more wider-ranging political change. A third strand of thinking has sought to comprehend the importance of spatial arrangements of services in shaping social life. Often inspired by Foucault, this work looks at the ways individual geographies are shaped by institutions, drawing on disciplinary categorizations and constructions of individuals as unhealthy, mad or dangerous, and therefore requiring confinement. Much of this work is historical, showing how institutional arrangements reflected hegemonic (see hegemony) (or sometimes competing) discourses — for example, the debate over \'sterilization versus segregation\' in the treatment of the mentally handicapped, with consequences for the spatial arrangement and location (as well as internal geography) of institutions (Radford, 1991). One could extend this to the socio-spatial elements of the provision of facilities for the mentally ill in contemporary societies (e.g. Dear and Taylor, 1982; Philo, 1997).

A final implication of all this is whether there is scope for a sub-discipline concerned with geographies of health and health care. The WHO emphasizes the social and political determinants of health and illness, suggesting that progress towards the laudable aim of universal good health is unlikely to be attained short of political or social change. For this reason some have suggested that geographies of health and health care should be subsumed within the broader field of social geography, drawing the wrath of those who still insist that medical geography plays a potentially crucial role in integrating many of the intellectual concerns of human geography (see the exchange between Kearns, 1993, 1994 and Mayer and Meade, 1994). (JM)

References Brown, M. 1995: Ironies of distance: an ongoing critique of the geographies of AIDS. Environment and Planning : Society and Space 13: 159-83. Cornwell, J. 1984: Hard-earned lives: accounts of health and illness from East London. London: Tavistock. Curtis, S. and Taket, A. 1995: Changing perspectives on health and society. London: Arnold. Dear, M. and Taylor, S.M. 1982: Not on our street. London: Pion. Dorn, M. and Laws, G. 1994: Social theory, body politics and medical geography. Professional Geographer 46: 106-10. Dyck, I. 1995: Hidden geographies: the changing lifeworlds of women with multiple sclerosis. Social Science and Medicine, 40: 307-32. Gatrell, A. 1997: Structures of geographical and social space and their consequences for human health. Geografiska Annaler 79B: 141-54. Gesler,W. 1992: Therapeutic landscapes: medical issues in light of the new cultural geography. Social Science and Medicine, 34: 735-46. Golledge, R.G. 1996: Geography and the disabled: a response to Imrie and Gleeson. Transactions, Institute of British Geographers NS 21: 404-11. Imrie, R. 1996: Ableist geographers, disablist spaces. Transactions, Institute of British Geographers NS 21: 397-403. Kearns, R. 1993: Place and health: towards a reformed medical geography. Professional Geographer 45: 139-47. Kearns, R. 1994: Putting health into place: an invitation accepted and declined. Professional Geographer 46: 111-15. Matthews, S. 1993: Curriculum redevelopment: medical geography and women\'s health. Journal of Geography in Higher Education 17: 91-102. Mayer, J. and Meade, M. 1994: A reformed medical geography reconsidered, Professional Geographer 46: 103-6. Mohan, J.F. 1989: Medical geography: competing diagnoses and prescriptions. Antipode 20: 166-77. Philo, C. 1997: Across the water: reviewing geographical studies of asylum and other mental health facilities. Health and Place 3: 73-90. Pinch, S. 1997:Worlds of welfare. London: Routledge. Radford, J. 1991: Sterilisation versus segregation: control of the feeble-minded, 1900-38. Social Science and Medicine 33: 49-58. Scarpaci, J. 1991: Primary care decen-tralisation in the Southern Cone: Shantytown health care as a social movement. Annals of the Association of American Geographers 81: 103-26. Wallace, R. 1990: Urban desertification, public health and public order. Social Science and Medicine 31: 801-13. Wilkinson, R. 1996: Unhealthy societies: the afflictions of inequality. London: Routledge.



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