Chapter 1
Introduction

Introduction

The task of introducing a book such as this is not inconsiderable, especially as it has been co‐authored by scholars who place themselves very differently within, and in some cases without, the field of health geography. We should be clear about this latter point right from the outset. This text is a critical introduction to health geographies – deliberately presented in the plural rather than the singular form – and it is written by scholars with different and sometimes quite jarring epistemological perspectives and ontological positions. Like many of our contemporaries, we do not see health geography as a single field of study and how we each approach the question of health differs considerably. Moreover, some of us are less concerned with health as an object of investigation than we are with subjects that appear to fit a little more comfortably under the rubric of medical, or perhaps more appropriately biomedical, geography. For example, there is as much focus on disease and biomedicine in this textbook as there is on questions of health and health care. In practice, then, this book works across disciplinary and sub‐disciplinary boundaries that have been established by those writing within the field (e.g. Kearns 1993; Mayer and Meade 1994; Kearns and Moon 2002; Rosenberg 2016) but perhaps tend to overlook what is going on outside of it (e.g. Parr 2004; Philo 2000, 2007; Dorn et al. 2010).

As a second point of introduction we should also say a little about why we targeted our ideas for this book at the Wiley‐Blackwell Critical Introductions to Geography series. You will be aware that there are numerous textbooks covering the field of health geography, from Kelvyn Jones’ and Graham Moon’s (1987) classic Health, Disease and Society: An Introduction to Medical Geography to more recent, and sometimes a little more specialist, texts such as Robin Kearns’ and Wilbert Gesler’s (2002) Culture, Place and Health, Sarah Curtis’ (2004) Health and Inequality, Anthony Gatrell’s and Susan Elliott’s (2009) Geographies of Health: An Introduction and Peter Anthamatten’s and Helen Hazen’s (2011) An Introduction to the Geography of Health. To these texts on health geography, we might also add Melinda Meade’s various editions of Medical Geography (e.g. Meade and Emch 2010). Each of these books offers their readership invaluable insights into the field, however we were struck by the idea that the Wiley‐Blackwell series is committed to providing ‘broad and introductory’ textbooks with a ‘critical edge’. It was the emphasis placed upon criticality that was especially important to us and we believe should be important to you as readers. Here, it is not only a matter of how criticality is defined by us but how this commitment to criticality should shape the ways in which you approach this text. We will deal with the former of these points in the section that follows, but as readers we encourage you to examine the evidence that we present and consider the theoretical influences upon it. Be sure to interrogate the interpretations that we offer and to reflect on possible alternatives to them; think, for example, about what is present and what is absent in our readings of the field. Ask yourselves how persuaded you are by the arguments and opinions that we present and the conclusions that we draw. In sum, you should be aware that we have made decisions in our research and writing and we encourage you as readers and potential future authors to enter into academic debate with us.

A Critical Introduction to Health Geography?

If we take a fairly straightforward view of what health geography is concerned with, we might suggest that it questions how the interaction of humans, materials and the environment shapes and constrains health, wellbeing, survival and flourishing. At the heart of this interaction are complex social, economic and political issues which can complicate and extend conventional debates about health. An examination of these issues and how they affect people around the world, often very differently, can unearth a myriad of health costs and benefits. For example, rising conflict in the Middle East has been quickly followed by outbreaks of polio, which has re‐emerged because efforts to immunise children are being hampered (Blua 2013). Meanwhile, more than 5 billion people worldwide now have a cell phone, leading to a number of efforts to use mobile technology to revolutionise the way medical care and health information are delivered, particularly in the rich countries of the Global North (Hampton 2012). In each case, health is entangled with complex ethical, social and political concerns over the autonomy, control and care of humans. These are concerns that demand critical health geographers engage with ideas, debates and perspectives from outside of their direct fields of interest. Equally our response to them ensures that we contribute to knowledge and understanding of a multitude of health and biomedical issues that is interdisciplinary in nature.

So health geography is a broad field of enquiry, as this book amply demonstrates. Yet, we agree with Robin Kearns and Damian Collins (2010) when they state that at the core of the sub‐discipline lies, or at least should lie, a concern for social justice. This is as good a place to start as any when considering the question of what a critical introduction to health geography might entail. This concept evolved from foundational principles associated with the ‘social contract’ (for a full history of this concept, see Rawls 1971). The social contract is the recognition that individuals have rights such as dignity and autonomy with which the state cannot unduly interfere. Individuals allow the state to rule only through laws which, at least in theory, pursue the principles of freedom and equality. This ‘pact’ allows society to function as a whole and gives legitimacy to the authority of the state over the individual. Of course, since these early foundational principles, different interpretative theories of social justice have developed which sit on top of the foundational principles. Governments have tended to have either a ‘right’ (liberal) or ‘left’ (social democratic) political understanding of the social contract. On the right, governments tend to interpret the social contract to mean the minimum possible role of the state: individuals should be completely untethered to pursue their own ends. The state is despised as a wasteful villain that obstructs the self‐equilibrating market system. The corollary is that the state provides minimum protections to those who ‘fall between the cracks’. On the left, governments tend to interpret the social contract to mean the state should provide a more supportive role and protect against the more self‐destructive forces of the capitalist system.

When considering this question, critical health geographers must therefore be cognisant of the underlying political philosophies of the state as they can have significant effects on the health of individuals. A value judgement can be made about the social justice element of particular policies and their impacts on certain individuals, groups or even the population as a whole. For example, Danny Dorling’s (2014) geographic work in the United Kingdom has mapped the health and distribution of wealth of its citizens and argues that as a result of the British state’s commitment to neoliberal policy, including the more recent politics of ‘austerity’, the mere accident of being born outside the nation’s wealthiest 1 per cent will have a dramatic impact on the rest of your life: it will reduce your life expectancy, as well as educational and work prospects, and affect your mental health. To Dorling’s voice we can add that of Clare Bambra who, in her work with Ted Shrecker, recently argued that there are clear parallels between the health effects of neoliberalism and the ‘unfettered liberal capitalism of the 19th century’ (Shrecker and Bambra 2015, p. 17). Specifically, they argue that now as then the conditions in which people live, work and play are vital in determining how long and in what state of health people live.

Collectively, this work serves as a useful example of how to be ‘critical’. The value judgements presented by all of these scholars are drawn from thoroughly‐researched, empirical findings. Based upon their generally realist epistemological positions, Dorling and Bambra recognise what evidence is essential to validate their argument as well as how much evidence is needed to support their conclusions. However, an important caveat here is that to be critical, one should remain equally alert to the nature of evidence itself. For example, the idea of evidence‐based health care (EBHC) has quickly become a global priority. Yet, the wide‐ranging critique of EBHC highlights that, although it is appropriate that the best health care is provided in the best known ways, EBHC goes far beyond this objective, becoming a powerful movement in itself that espouses a dominant scientific worldview that selectively legitimises and includes certain forms of knowledge but degrades and excludes other forms, such as qualitative ones. Critical health researchers argue that, in response, a critique is necessary for deconstructing this mode of thinking, and that resistance is ethically necessary given the powerful forces in play (Holmes et al. 2007).

Another way of thinking...