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Medical geography: critical medical and health geography?

Hester Parr
Prog Hum Geogr 2004 28: 246
DOI: 10.1191/0309132504ph484pr

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 Progress in Human Geography 28,2 (2004) pp. 246-257

Medical geography: critical medical

and health geography?
Hester Parr
Department of Geography, University of Dundee, Dundee DD1 4HN, UK

I Introduction
Several commentators on the current state of human geography have recently criti-
cized cultural geography for its influence on the theoretical and empirical foci of the
wider discipline, and for distancing the discipline from issues of supposedly 'politi-
cal' and 'practical' concern (Hamnett, 2003; Martin, 2001a; 2001b). Others, mean-
while, are simultaneously celebrating the success that geography is having in
terms of its 'involvement in the public realm' (Thrift, 2002: 293). Increasingly, though,
there is a debate about whether the cultural turn in human geography has precipi-
tated a growth or a decline in critical praxis and policy relevance (Martin, 2001a;
Nash, 2002), although some have questioned the need for such introspective and
repetitive disciplinary games (Gregson, 2003). This debate has crystallized in distinc-
tive ways, with proponents of 'policy relevance' effectively aligning with more rad-
ical activists in a pincer-like movement on the cultural turn. For those advocating
policy relevance, mainstream human geography has become dangerously subjective
and theoretical, while for radical scholars the cultural turn is simply not delivering a
sufficiently activist and interventionist politics (Hague, 2002). Both camps have
adopted a label and language of 'criticality' when examining the cultural turn,
although there are important differences in terms of how this geographical scholar-
ship can be seen to work either within or outside establishment politics (Castree,
1999; 2002). Broadly associated with this development is a substantial correspon-
dence on journal pages and in email lists concerned with exactly what is 'critical
human geography' (see the virtual archives of the crit-geog-forum for examples).'
Although I will not review this material here, in general terms 'critical' geography
is defined by research work which is seen as: international; 'relevant'; theoretically
sophisticated; interdisciplinary in perspective; alert to questions of global scale
and difference; as sensitive to the political-economic as it is to the sociocultural;
and 'at the cutting edge2 of developments in the sciences, social sciences and huma-
nities' (Thrift, 2002: 296). These rather high stakes raise questions about how medical
and health geography might fit into this picture, and reviewing aspects of what
might be understood as recent 'critical' research in this field shall be the focus of
my third and final review.
.uArnold 2004 10.1 191/0309132504ph484pr

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 Hester Parr 247

In the last year (2002-2003) debates about 'directions' in medical and health
geography have touched on questions of 'criticality'. Kearns and Moon (2002: 606),
in reviewing the last ten years of medical geography, argue that a 'metamorphosis'
has taken place, albeit noting that the contemporary research efforts of a range of
geographical scholars emerge from a rather limited set of locations and interests.
In other words (and echoing Phillips and Rosenberg, 2000), medical and health
geography is predominantly an Anglo-American affair, rather than 'international'
and 'global' in perspective. Despite this, Kearns and Moon (2002: 615), use the
term 'critical health geography', borrowing from Painter (2000: 126-28) to explicate
what is at stake here:
... a rapidly changing set of ideas and practices within human geography, linked by a shared com-
mitment to emancipatory politics within and beyond the discipline, to the promotion of progressive
social change and to the development of critical theories and their application in geographical
research and political practice.
This definition of critical geography, perhaps combined with the more precisely
specified list of my own above, begins to reveal (although only partially) some
aspects of what is being discursively constructed as 'the cutting edge' within the dis-
cipline. So how does medical and health geography fare in these disciplinary evalu-
ations? When discussing 'critical health geography' Kearns and Moon (2002: 615) are
actually quite vague, only specifying past work on health inequalities as proof that
geographers have been engaged with work involving 'opposition to unequal and
oppressive power relations [and] a commitment to social justice' (see also Asthana
et al., 2002). Beyond that, they argue, health geographers demonstrate their 'critical-
ity' through either their teaching (as a form of activism) or 'relevant' research part-
nerships or associations with the state, medical professionals, public health
workers and analysts as well as other disciplines. There is an implicit sideswipe at
more cultural geographies of 'illness and impairment' (Kearns and Moon, 2002:
617) in which the relevance of critiquing outdated stereotypes of medicine is ques-
tioned and the value of 'robust basic or applied research' is signalled. Hence, even
from authority figures within medical and health geography who have been actively
involved in pushing forward 'a cultural turn' in the subdiscipline, there are signs
of concern and re-evaluation (although this should not be overstated: see Gesler
and Kearns, 2002). In what follows below, I review some aspects of current work
with a view to highlighting how geographers who work in this area are constructing
and responding to notions of 'criticality'. I consider how their work might measure
up in light of current concerns about relevancy and 'the cultural turn'.

11 Critical theory?
Despite the definitions offered above, medical and health researchers clearly see
'critical' studies in different ways. In a recent paper concerning 'critical geographies
of public health', Brown and Duncan (2002) argue that the reinvention of medical
geography as 'health geography', and an allied engagement with theory, has facili-
tated new and more critical understandings of health and societies, although this is
still limited. One example is their focus on recent research concerning health inequal-
ities (cf. Boyle et a!., 2002), which combines biological, social and environmental fac-
tors as a means by which to explain variations in health status. Brown and Duncan

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248 Medical geography

celebrate, and yet also hold reservations about, this development. They see strong
traces in this work of 'a rather uncritical acceptance of the social model of health'
(p. 363), associated as it is with pervasive forms of governance, regulation and social
control in developed countries, which still remain undertheorized. Geographers are
hence encouraged to utilize further the theoretical resources at their disposal, such as
those offered by Foucault on health and subjectivity, to interpret new public health
initiatives and the ways in which these facilitate more and more aspects of social
life coming under a medical gaze (Parr, 2002a). Advocating a poststructuralist
critique of how 'health has become a central motif for the organization of our lives
within late modern Western society' (Brown and Duncan, 2002: 367), as though
this is something to be resisted, their approach contrasts with other 'critical' research.
Some scholars point to other spatial contexts (e.g., the developing world) which
remain distinctively undertheorized in terms of how every aspect of human life is
and should be implicated in the achievement of health (see Craddock, 2001, and associ-
ated comments below). Here 'criticality' is clearly defined in relation to the uses of
theory. For some, this is best demonstrated when health geographers utilize complex
ideas from wider human geography and beyond in order to conceptually interrogate
the relations between health and society, rather than just engaging in empirical
endeavour (Gesler and Kearns, 2002).
However, even predominantly theoretical writings, especially emerging from
researchers associated with the 'cultural turn' (presently the ones under disciplinary
suspicion), also advocate 'relevance'3 and 'applicability', as these elements are clearly
currently constructed as being key components of 'critical geography'. Refreshingly,
though, 'relevance' can occasionally be achieved as a result of being prepared to
engage with philosophical complexity. Take Davidson's (2003: 109) recent enrolment
of Sartre and Goffman in the understanding of agoraphobic anxiety:

By bringing geographically informed, sociological and philosophical perspectives regarding the

problematic nature of social existence in contemporary western society to bear on agoraphobia,
we could gain new and thoroughly different insights into the disorder, which lie beyond the
reach of, for example, clinical and indeed social psychology.

The implied value of such theoretical work is that ultimately it may have the
potential to transform clinical practice, precisely because such work is able to
'think outside the box' in terms of particular disease conditions (see also Gandy
and Zumla, 2002a; 2002b; Porter and Ogden, 2002). Do such cultural geographies
of health have any more or less critical potential than assessments of neoliberal
political-economic rationalization and resultant impacts on health services
(Barnettand Barnett, 2003; Wilson and Rosenberg, 2002a), or debating the best way
to conceptualize place effects on health inequalities (MacIntyre et al., 2002)? I suspect
they do not. This is not to advocate a baseless relativism in health and medical
research, but merely to reiterate a warning that only valuing research constructed
as 'objective, truthful and hard' and devaluing theoretical, narrative-based
approaches as 'subjective, untruthful and soft' (Kearns and Moon, 2002: 618) poten-
tially constrains the subdiscipline in terms of why and how it could matter beyond
academic geography.

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 Hester Parr 249

Ill The politics of health (research)

Infused in the comments above, and the works to which they refer, are two related
points about critical geography. The first is that critical research can involve praxis:
forms of relevant activism (direct action) that potentially might make a difference
to inequitable processes. The second is that critical research can involve critical
thinking: the development of new ideas and theoretical possibilities that hold the
potential for better understanding of social processes and spaces, as well as possibly
facilitating different pathways to praxis. As an academic field, medical and health
geography is arguably weak in relation to both, although there is a tradition of
incisive research into health policies - social modalities strongly associated with
inequality - thereby suggesting an orientation to the latter point. Currently, there
is evidence of a significant body of work that comments on health policies in both
developing and developed world contexts (see below). Assessing whether this
work facilitates or achieves progressive social change and emancipatory politics,
as suggested in Painter's (2000) definition, is difficult, although it is certainly the
case that some medical geographers are actively trying to 'bridge the gap to the
applied policy world' (Atkinson, 2002: 113-24). Speaking back to wider debates in
human geography about the critical and the cultural, what is refreshingly evident
in this research is the imaginative ways that 'culture' is being enrolled into analyses,
rather than being rejected as a frothy diversion from the main projects of human
geography (cf. Hamnett, 2003).
Atkinson (2002), for example, evaluates the decentralization of the management of
health systems in low- and middle-income countries. Specifically targeting informal
political cultures in northeast Brazil, she seeks to understand the benefits and draw-
backs of so-called 'rational' health systems models. By 'staying around a little longer
and watching a little more closely' (p. 116) than health systems researchers have pre-
viously done, Atkinson begins to understand the scales of influential political cul-
tures in (in)equitable health systems. Noting that 'researchers and policy makers
in the field of health systems have been uneasy with the notion of the informal or
the cultural as a major category of analysis' (2002: 121), she nonetheless contributes
to a critical deconstruction of health policy by understanding 'the cultural', not as a
catch-all for explanations of 'irrational' organization, but as dynamic set of processes
through which participatory and empowering policy making might evolve. What's
interesting here is that Atkinson makes an appeal to health researchers to draw on
the vibrant field of cultural geography as a way of making applied research more
and not less relevant. Similar perspectives are also presented by Craddock (2001) con-
cerning AIDS in Africa.
There is a continuation of substantial research on the past and present political
dimensions to health services provision in the west (for example, Andrews and
Phillips, 2002; Curtis et al., 2002; Joseph and Moon, 2002; Mohan, 2002, 2003;
Moon et al., 2002; Wilson and Rosenberg, 2002a). Moreover, there is increasing evi-
dence that attention to cultural geographies of identities assists in understanding
how health issues and policies involve differential levels of public participation,
understanding and support in a variety of communities (Baer, 2002; Barnes et al.,
2002; Coast et al., 2002; Litva et al., 2002). Law (2003: 8) takes AIDS as an example
through which to view how the relations between identities, places and health
concerns play out in local politics. Claiming that research on attitudes towards

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250 Medical geography

local government funding of AIDS-related services among different social groups in

West Hollywood (USA) is 'not just of academic interest, but directly relevant
to political debates over local government funding and service delivery', Law,
like others, is clearly sensitive to accusations of 'irrelevance'. Understanding how
communities identify with changing health policies is also a concern of Barnett and
Barnett (2003), who note that there are few attempts to document community resist-
ance strategies to hospital restructuring in specifically rural areas. While recognizing
that 'cultural perspectives provide valuable insights into the 'languages' of restruc-
turing and resistance' (p. 61), these authors also feel that more 'in-depth' studies are
needed which recognize key (pre)conditions to social actions around health.
For some, then, a sensitivity to both geographical cultures and cultural geography
perspectives remain crucial to producing 'critical' research work, although resear-
chers are proving sensitive to questions of relevance and related accusations of
superficiality.
Beyond explicitly stating the potential relevance that critical and cultural health
research might have, other medical and health geographers have been engaged in
a variety of applied research efforts, some of which seeks directly to influence
local health-related policies and planning (a kind of praxis). Building on a minor
tradition of applied GIS-health related work (acobson and Kitchin, 1997; Golledge
et al., 1991), Matthews et al. (2003: 35) report on the role of GIS in assisting route
access to urban areas for disabled people who use wheelchairs. Maintaining
the emancipatory implications of such research, the authors claim that GIS is not
just a technological 'fix' for health and mobility problems, but rather 'a device that
has the capability of informing able-bodied decision-makers about the multifarious
ways in which towns cripple their population'. Others are also increasingly claiming
critical relevance through applied GIS work (Foley, 2002; Kistemann et al., 2002;
Lovett et al., 2002), although note that even here geographers have more work to
do to 'expressly quantify the value of GIS and geography' to healthcare professionals
(Foley, 2002: 94).

IV Difference: gender and health

Critical geography has also been associated with sensitivity to difference. In terms of
gender difference, it could be argued that health and medical geographers have been
slow to contribute to this research area. In the 10th International Medical Geography
Symposium at Manchester (2003), only three papers explicitly mentioned gender, men
or women in their titles: and, although some papers did actually include reflection
on gender and health, it was not a key focus of concern for many. In 1989 medical
geography was considered 'genderless and colourblind' (Pearson, 1989; see also
Gesler and Kearns, 2002: 100-105; Panelli and Gallagher, 2003), and despite important
recent exceptions (e.g., Moss and Dyck, 2002; see also Allison and Harpham, 2002) new
work is needed to counter this negative assessment in order to emphasize how gender,
race and class intersect to produce particular geographies of health for both women
and men. A relief from this neglect is a recent edited collection (Dyck et al., 2001)
which concerns geographies of women's health, asking how gender constitutes a
major axis of difference that affects health status. Taking an international perspective,
the collection examines women's lives across public and private spheres in different

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 Hester Parr 251

environmental and cultural contexts. Here women are not just constructed as passive
demographic containers through which patterns of health and illness can be redrawn,
rather they are seen as 'exploring and using active strategies in managing health and
illness' (Dyck et al., 2001: 3) through their accessing of both formal and informal health
care resources. This work utilizes feminist scholarship, building on the past efforts of
the likes of Moss and Dyck (2001) in order to help theorize how 'webs of meaning
about masculinity and femininity are translated into the organization of politics and
economies and attendant social life and health' (Dyck et al., 2001: 4). In particular,
and taking up the theme of critical medical and health geographies, some chapters
seek not only to explore the experiential dimensions to ill health and the discursive
readings of (un)healthy bodies (Davidson, 2001; Ellaway and MacIntyre, 2001; Litva
et al., 2001; Moss and Dyck, 2001; Underhill-Sem, 2001), but also seek explicitly to
address inequitable political and structural contexts framing women's health in differ-
ent parts of the world (Craddock, 2001; Glassman, 2001; Gober and Rosenberg, 2001;
Thomas and Rigby, 2001). The latter chapter stands out in terms of the particularly
critical stance taken on the compiling of data for the European Women's Health Project
in the late 1990s. Here the authors highlight how 'critical' research (projects and data
which revealed inadequate national health policies) on women's health was at best
avoided by the EU and, at worst, was surpressed if considered not to be politically
neutral. The result is a continuing political neglect of women's health in Europe at
both national and EU member state level, and a clear need is identified for more
targeted policy-relevant research which directly acknowledges the economic, social
and cultural determinants of women's health across a variety of scales.
Craddock (2001) echoes some of Thomas and Rigby's wider points about the limi-
tations of biomedically orientated research which is often unproblematically used to
inform policy agendas for funding solutions into women's health issues, in this case
with respect to HIV/AIDS in East Africa. She also argues that wider theoretical
frameworks need to be employed to understand fully the relationship between
women, HIV and AIDS. Complementing the recent work which theorizes geogra-
phies of risk (for references see Parr, 2002b), she recognizes that HIV and AIDS infec-
tion is 'embedded in social economies of impoverishment and gendered inequity'
(Craddock, 2001: 42-43), and not just a result of individual behaviours and risky sex-
ual practices in any simplistic sense. Drawing together theoretical influences from
development studies, and feminist theory, as well as from more general poststructu-
alist approaches, Craddock effectively offers us a multilevel 'critical' approach to one
particular disease category. This may serve as a useful benchmark for other studies of
ill health, especially ones often at risk of being rather unidimensional. The role for
geographers in mapping women's (ill) health as a personal-yet-political reality is
clear, since many of these studies call for more localized analysis of health trends:
indeed, 'highly contingent relations of power, social economy and individual iden-
tity makes local studies a necessity' (Craddock, 2001: 55). In summary, then, there
is plenty of evidence that new 'critical' gender and health research is taking place
(see also Kerner et al., 2001; Pope, 2001; Tripathi, 2001; Manderson et al., 2001;
Williams, 2001; 2002). What may be missing here, though, is an explicit focus on
(un)healthy masculinities (for a recent exception see Weston, 2003) as opposed to
an approach in which men's health status is an unmarked norm.

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252 Medical geography

V Cultural geographies of health

Cultural geography and its influence on medical and health studies has received
very positive assessments from some (Gesler and Kearns, 2002), with little resonance
of the debates affecting the wider discipline (as above). 'The cultural turn continues
to be important for the geography of health', write Asthana et al. (2002: 170), although
there is a suggestion that the links between social, cultural and health geography are
weaker than they could be (but see Airey, 2002; Hall, 2002; Holt, 2002; Wainwright,
2002). For some, the influence of cultural geography in this field has continued to
lend itself to a focus on the relations between specific cultures and health (Wilson
and Rosenberg, 2002b). Wilson (2003), for example, looks at neglected emotional-
spiritual landscapes among First Nation peoples in Canada. She couches her work
as an investigation in 'everyday' geographies, as opposed to the 'events' and 'special
places' foci of much of the therapeutic landscape literature in health geography. She
also highlights the lack of attention to non-western place-health conceptions and, like
others cited above, criticizes health geographers for being reductionist and ethno-
centric in their studies. Moreover, she suggests that 'critical' health geographers
have rather simplistically just 'included' other voices in their work, rather than
take up the opportunity to think differently through them.
Reading the various cultural texts of health (Driedger and Eyles, 2003) differently,
in ways which challenge subdisciplinary thinking, is also increasingly a feature of
work being produced by cultural geographers who most definitely would not
label themselves as medical or health researchers. Some of the most innovative
work on health that has emerged in the last year includes Doel and Segrott's
(2004: 1) ironic work on the relationship between consumer cultures and com-
plementary and alternative medicine (CAM). Written through a poststructuralist
theoretical lens, these authors argue that CAM has been neglected precisely because:
post-medical geography has found it extremely difficult to come to terms with the disconcerting
fusion of healthcare and consumer culture, and its dispersion across a vast array of materials and
practices that are often far removed from the established concerns of the subdiscipline.4
Addressing the dispersed geography of CAM through an analysis of the mass
media (see also Doel and Segrott, 2003), CAM is interrogated as a set of disparate
materials and practices which the authors argue are, in principle, no different to
orthodox medicines. There is an explicit challenge here for medical geographers to
'move beyond medical geography', to consider the 'unlocalizable' everyday spaces
of 'oils, needles, sacred space sprays, crystals and reiki', and to move beyond simply
'decentring' dominant biomedical traditions to understand the dispersal of the medi-
cal itself. The theoretical and empirical focus on consumer culture 'with its profusion
on objects and sensations' allows this exciting shift (Doel and Segrott, 2004: 12; see
also Holloway, 2000).
Would such work be understood as 'frothy' and distinctly uncritical by the likes of
Hamnett (2003)? Probably. Although, as research that highlights the complex ways in
which contemporary human subjects are seduced into health in risk societies, I would
argue that such an approach is important in understanding key aspects of twentieth-
century socialization (Doel and Segrott, 2003: 23). Moreover, this work proposes a
theoretical problematic for medical geographers, as it argues that 'by clinging to
its ends, medical, post-medical and health geography have failed to notice that

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 Hester Parr 253

many of the means have long-since slipped away' (Doel and Segrott, 2003: 36). Cul-
tural geographers such as these, then, are thus urging medical and health geogra-
phers to think outside, and beyond, usual boundaries of medical beliefs,
treatments, bodies and authority. While I welcome the sense of revolution, and differ-
ent forms of critical thinking brought about by such work, I nonetheless caution that
we should not lose sight of the very located experiences of illness that bring some to
encounter CAM in the first place. The tensions between a changing medical geogra-
phy and such poststructuralist writing in the wider discipline hold the promise of
productive future encounters.

VI Conclusion
Reading debates about critical geography into a particular subdiscipline is clearly a
flawed and messy task. Partly this is because the project of 'critical geography' is
fluid and ill defined, and partly because medical and health geographers are only
just beginning to respond explicitly to questions about relevancy, praxis, difference,
internationality, etc. such as those outlined in the introduction. For some, of course,
such criteria for research have always been benchmarks, and it is only in light of a rela-
tively recent 'cultural turn' that such questions have become more pertinent. The
distinctive movement against cultural geographies, evident in the wider discipline,
seems muted in this field to some extent, although researchers are clearly sensitive to
accusations of irrelevance. Meanwhile, research in and on cultural geographies of health
and healthcare is proving to be theoretically dynamic and provocative in producing
critical insights into the relations between health and societies in different spatial con-
texts. However, some would still argue that there is little evidence of 'critical' research
in this subdisciplinary field. On mentioning the title of this report to a couple of my
fellow participants of the 10th International Medical Geography Conference (2003) in
Manchester, the response was surprised laughter and the question 'is there any?'.
To end on another, slightly cautionary note, it is increasingly evident that across the
wider discipline more and more researchers, many of whom who do not identify as
medical or health geographers, are beginning to engage, encounter and write about
health-related issues. Recent conference sessions have been organized on genetic
geographies (IBG, 2002), geographies of health knowledges (AAG, 2003) and psychol-
ogy and space (AAG, 2003) and there have been writings on spaces of therapy (Bondi,
2003; McCormack, 2003), health practices (Pain et al., 2001) and complementary and
alternatives medicines (Doel and Segrott, 2003; 2004); all of these are just some
examples of such a development. These efforts contain vastly different versions of
'critical' geography, and vary in terms of whether they display any reference to medi-
cal and health geography as a subdiscipline. The result is none the less that health and
medical issues are assuming a high profile in human geography, with some research
even being constructed as the enviable 'cutting edge' (Thrift, 2002: 296). Although this
is certainly to be celebrated, for those for whom medical and health geography is an
important subdisciplinary home, challenging questions may increasingly need to be
asked about its critical relevancy to the rest of human geography.

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254 Medical geography

Acknowledgements
Thanks to Ed Hall and Chris Philo for casting a 'critical' eye over the final product.

Notes
1. At http://jiscmail.ac.uk/archives/crit-geog-forum.html.
2. Castree (1999; 2002) has recently raised questions about how scholarship is constituted as 'cutting
edge' work. In the context of the RAE and similar bureaucratic practices, it is ironic that 'critical' work
gets domesticated as a badge of quality and achievement in the context of conservative management
strategies that seek to regulate academia.
3. The concept of 'relevance' is a term noted as one which has been narrowly constructed in the past
(Johnston, 2000: 696). In current debates about critical geography there is a sense in which 'relevance' is
once again becoming synonymous with 'application' and the disciplinary capacity to help solve major
social problems.
4. The paper notes the work on consumerism in health services from the likes of Kearns and Barnett
(1997). although it neglects to cite more recent examples of this take on geographies of health and
healthcare; see Kearns et al. (1999; 2000; 2003).

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