Health geography III

I Introduction

Other parts of human geography appear to be more motivated by theory, sometimes even where there is only scant or no evidence to support theory. In contrast, health geography remains mainly motivated by what can be observed and measured with only scant or no attention paid to theory, notwithstanding pleas by Kearns (1993) and, much more recently, by Rosenberg (2014) and Grady and Wadhwa (2015). Health geographers are increasingly leading and contributing to health research. As a result, health geography is among the most robust sub-disciplines of human geography. Even with this progress, however, where does health geography stand in its theoretical development?

To answer this question, this report is organized around a set of topics that have dominated much of the recent literature in health geography: the importance of neighbourhoods, green spaces/blue spaces, density, walkability, and vulnerable populations. It is no coincidence that most of these topics were discussed in Rosenberg (2014, 2016). It is also no coincidence that most of these topics are dominated by what can be observed and measured, but where the underpinning theories are weak or often unexamined from any type of critical perspective. I return to these topics given that they continue to dominate the published research and in order to answer the question asked above. I also want to examine three more specific questions left unaddressed by Rosenberg (2014, 2016). First, to paraphrase the British rock band The Who, are we really singing ‘the same old song’ with ‘a few new lines’ in the search for a ‘new song?’ Second, are health geographers generating new ideas or new determinisms, specifically new versions of environmental determinism? Third, is health geography falling into the neoliberal trap of focusing on the middle class and middle-class values, thereby losing sight of those who are truly in need and have the fewest resources to effect change to their health, lives and the places where they live?

II Neighbourhoods

The underlying hypothesis in the research on neighbourhoods is that physical designs – or alterations in the physical designs – of neighbourhoods have either positive or negative effects on health through a causal chain of changes in physical activities to changes in physical or psycho-social health to changes in a particular health outcome (e.g. obesity). A corollary of the main hypothesis is that physical designs that increase physical activity (e.g. making a neighbourhood more walkable) will lead to better health. Typical of the studies that seek to demonstrate the general hypothesis and its corollary is Christian et al. (2015). Based on a review of the literature, they develop a conceptual framework incorporating measures of neighbourhood and home thought to facilitate or constrain active and passive play, physical activity, social interaction, and exploration and stimulation in relation to early childhood development. In a highly innovative study, Gibson et al. (2015) simulate the costs and benefits of redesigning a neighbourhood to make it more walkable. They conclude that the economic benefits of better health far outweigh the economic costs of the investment in better sidewalks. They nonetheless admit that they had difficulty in finding any research to demonstrate conclusively that changes in the physical infrastructure do indeed lead to changes in walking behaviour. The neighbourhood ‘walkability’ research as exemplified in the work of Christian et al. and Gibson et al. leaves two important questions unanswered. First, whether people who are committed to walking walk regardless of the physical infrastructure. Second, whether changing the physical infrastructure of walking encourages more people to walk or simply provides a more walkable environment for those who already do walk.

Enabled by new technologies, many of the walkability studies are now using global positioning systems (GPS), accelerometers, portable heart monitors and the like to collect enormous amounts of detailed data on relatively small samples (e.g. Oliver et al., 2015). Paradoxically, in the quest for more data and more detailed data, the samples chosen are often unlikely to be representative of the general population. For example, in the study of San Diego and Seattle, by Kurka et al. (2015), the percentage of the subsamples with a college education in San Diego ranged from 52.2 per cent to 69.1 per cent and in Seattle from 71.8 per cent to 78.5 per cent. In all subsamples in both cities, over 90 per cent of participants were married.

Should we be concerned that the findings from such studies are being used to argue for changes in the built environment when the studies so clearly represent the values of the better educated, those with the most time to walk and to use recreational spaces, and are based on improving walkability in neighbourhoods that are not necessarily representative of those most in need or even the neighbourhoods most in need of physical infrastructure improvements? More critically, are the values and constraints of people from the most socio-economically and marginalized backgrounds, and especially of those who cannot walk at all, being properly taken into account in these studies?

Another question that needs to be asked is whether, if the most socio-economically and marginalized groups in our communities were asked to rank order infrastructure improvements needed in their neighbourhoods (e.g. better schools, better health care facilities, etc.), where would improvements to any form of active transportation infrastructure be ranked? What is also often unquestioned in many of these studies is whether more data provide any more insights into causality, or whether they simply replicate the findings of previous studies with much more detailed data about the correlates between health status of the samples and the neighbourhoods in which they live.

Often studies that claim to focus on neighbourhoods, the built environment and health really focus mainly, if not exclusively, on the socio-demographic and socio-economic characteristics of the population and their lifestyle behaviours in those neighbourhoods. Even where and when the neighbourhoods are meaningfully incorporated into these studies, the importance and relevance of the built environment is often overwhelmed by well-known and well-understood socio-demographic (e.g. age) and socio-economic (e.g. income) factors, rendering the measures of the built environment as of minor or no significance at all.

As the characteristics of the people and the neighbourhoods become conflated, the danger arises that the importance of the built environment is given more importance than the evidence might actually suggest. Using data from four New Zealand cities, Ivory et al. (2015) address this conflation by tackling the interaction effects between gender, working status, car access and income as set alongside measures of streetscape, a neighbourhood destinations accessibility index and a measure of street connectivity. Similarly, in Toronto, O’Campo et al. (2015) examine the interaction effects among a range of specific health outcomes where the interactions modelled are gender and age with neighbourhood disadvantage, community resources, neighbourhood problems, informal social control and neighbourhood social cohesion. In both studies, the researchers find some evidence to support the modelling of interaction effects. There are, however, two limitations to their research that they acknowledge: the limited number of interaction effects tested, and whether there are other measures and interaction effects that they have not taken into account. Nevertheless, the findings from these studies are good starting-points for the next wave of research to begin sorting out the relative importance of, and the kinds of interactions occurring between, the characteristics of local populations and the characteristics of their neighbourhoods with respect to health outcomes.

Although they do not address neighbourhoods per se, research by Moon et al. (2015) focuses on an issue that is often raised in health promotion research, but has not previously been tied to the geography of health inequalities at any geographic scale. They analyse the impact of functional literacy (FL) and numerical literacy (NL) on self-assessed health and the presence of long-term health conditions. As health care services and decision-making become increasingly complex and more of the decisions are downloaded to the individual, the findings of Moon et al. point to the important role that FL and NL are likely to play as people are forced to manage an increasing part of their own health care. The research by Lovell et al. (2015) ought to be seen as complementing the research by Moon et al., since she and her colleagues argue that community capacity might also be a key factor in the ability of communities to improve health collectively. The research by Moon et al. and Lovell et al. is also significant at a broader level. The decisions to reconfigure physical infrastructure of neighbourhoods in the name of improved health are complex and expensive. Making these decisions is ultimately a political act that assumes decent levels of knowledge about complex issues and the assent of the people living in the neighbourhoods affected, but is this knowledge and assent only likely to arise in the neighbourhoods of the well-educated, hence perhaps only serving to increase health inequalities between these neighbourhoods and others elsewhere?

What the above studies do not address at all, however, is a deeper critique of the ‘obesogenic environment’ literature as set out by Colls and Evans (2014). These authors call for a reconceptualization of obesogenic environments that is free of the moral assumptions about what is a healthy body and neighbourhood, thereby avoiding what amounts to new forms of environmental determinism. Colls and Evans do not dismiss the need to take into account obesogenic environments. They are, however, calling for more critical thinking on how built environments are produced in the first place, and about who is implicitly or explicitly excluded by the very nature of how conventional neighbourhood and walkability studies are framed.

III Green spaces/blue spaces

Arguably, the green spaces/blue spaces literature is divided between those researchers who see green spaces/blue spaces as therapeutic landscapes and those researchers who see green spaces/blue spaces as a variable to be measured and accounted for as part of a multivariate approach to the built environment. For the former group of researchers, the implicit assumption is that green spaces/blue spaces are imbued with meanings and values that are quantitatively immeasurable, but remain inherently good for both physical and mental health. For the latter group of researchers, the implicit assumption is that the greater the amount of green spaces/blue spaces associated with a given neighbourhood, the greater the (measurable) positive impact that will result for the health of the people living in those neighbourhoods.

The idea of green spaces/blue spaces as therapeutic landscapes continues to endure, but it is also difficult to see how adding to the range of therapeutic landscape studies is advancing any new ideas in health geography at a theoretical level. Some have tried to move thinking forward on therapeutic landscapes by linking their research to inter-subjectivity and relational and non-representational theories (e.g. Foley, 2015; Foley and Kistemann, 2015). Wood et al. (2015) meld past landscapes (nostalgia) into present landscapes (solastalgia) as a way of thinking about designing current therapeutic landscapes. They argue that their nostalgia/solastalgia framework offers a way to reduce some of the controversies which inevitably can be linked to the closure of health care facilities and the building of new health care facilities on the same or other sites. Other research might be better read for its methodological innovations. Asking people to reveal their views of green spaces/blue spaces through photos (e.g. Coleman and Kearns, 2015; Windhorst and Williams, 2015) and walking interviews by Finlay et al. (2015) are methods that might be extended to research in other areas of health geography.

What is disconcerting, however, is the direction of some quantitative research on green spaces that comes from a very different research tradition. Carrying out a classically designed systematic review, Bancroft et al. (2015) find that only five articles reported a significant positive association between parks and physical activity, nine studies found no association and six studies had mixed findings. In a Swedish study, Weimann et al. (2015) have attempted to measure the effects of changing exposure to neighbourhood greenness on general and mental health, to find only weak beneficial effects on either general or mental health resulting from ‘increased neighbourhood greenness’.

On one level, it is difficult to argue that green spaces/blue spaces are not inherently needed as positive features of a liveable city, but how green spaces/blue spaces are theorized in connection to people’s health deserves more critical thinking. Is there a contradiction in arguing for the expansion of green spaces/blue spaces per neighbourhood if the benefits to physical or mental health are only marginal? What if the expansion of green spaces/blue spaces ultimately reduces urban density but simultaneously increases the need for more transportation services and infrastructure? The argument might be advanced that this outcome increases active transportation, meaning more people walking, but are the net benefits really justified? Are researchers who argue for more green spaces/blue spaces unwittingly insisting that the ideal built environment is in fact an idyllic suburban middle class neighbourhood where everyone has a front and back garden connected to their home, ‘road calming’ street layouts, and green spaces/blue spaces strategically sited through out to provide public spaces for both organized physical activity (e.g. play fields for organized sports) and informal recreation (e.g. winding walking paths with view of the water)? The further question is to ask whether such idyllic landscapes are either realistic or meaningful for those segments of the population who either cannot afford to live in them or, if already residents, might end up dislocated from other places in the city where they are most likely to find meaningful employment. The entanglements here are legion; the unexamined implications of a certain trajectory of reasoning, what I term new species of environmental determinism, are many.

IV Densities

The underlying question motivating the research on density is whether greater density of outlets leads to positive or negative health behaviours or outcomes. Nowhere has this been more apparent in the health geography literature than in the research on ‘food deserts’, which continues to be the case. For example, Shearer et al. (2015) analyse dietary intake among adolescents, comparing the proportion of food locations within a residential buffer and outside but within a GPS buffer. Their research, in contrast to earlier research on food deserts, suggests that the importance of the neighbourhood food environment might be overestimated, and that outside the immediate neighbourhood the linkages between the food environment and dietary intake also need to be more carefully examined.

While the food desert literature continues to be an important part of the health geography literature (e.g. Bastian and Napieralski, 2016), much of the research on food deserts focuses on low-income neighbourhoods and the disappearance of food outlets (mainly large supermarkets) that are arguably sources of healthy foods in contrast to ‘convenience’ stores and fast food outlets that are contrasted as sources of unhealthy foods. The static nature of the studies is worrying, as too is the failure to take into account the declining numbers of people and population densities in neighbourhoods.

Some of the urban gardening literature has tried to make a virtue out of abandoned industrial and residential spaces as opportunities to improve local healthy food sources (new urban green spaces?). Yes, here too the question arises as to whether such a claim is really imposing a set of middle-class values as a solution and failing to tackle complex underlying problems, the latter being such issues as: how to address the needs of the most vulnerable parts of the population who live in not only food deserts but services deserts lacking public (e.g. health care services, schools, etc.) and private sector (e.g. shops for purchasing consumer goods) services, and/or simultaneously encouraging people to repopulate areas of cities that have been abandoned by most people and the shops and services required for healthy populations.

Beyond the food desert literature, other researchers have turned their attention to the links between well-known negative health behaviours (e.g. smoking, alcohol consumption and substance abuse) and the density of outlets. Falling somewhere between the green spaces/blue spaces literature and the literature on densities, McIntosh et al. (2015) examine the attitudes of parents and caregivers to a bylaw creating smokefree playgrounds. There was a high degree of consensus in favour of smokefree playgrounds regardless of the sex or socio-economic background of the respondents to the survey, the only negative being a fear of confrontation with someone who might want to smoke in the playground area regardless of the bylaw. Unsurprisingly, Richardson et al. (2015) connect alcohol consumption, density of outlets for the purchase of alcohol, and alcohol-related morbidity and mortality with neighbourhood income deprivation, finding that outlet density, more income-deprived neighbourhoods and higher negative health outcomes are all inter-related.

Health geographers’ participation in intervention studies is relatively rare. Mason et al. (2015) show that peer networks and their activity spaces can have a mediating effect on risky behaviours (e.g. tobacco and marijuana use). In a follow-up paper, as part of an intervention study to reduce smoking among urban youth, Mennis et al. (2016) show how tobacco outlet density and the effects of a text messaging-based intervention work in opposition to each other in affecting future smoking behaviour. McCann and Temenos (2015) move from the local to the global in their investigation of ‘drug consumption rooms (DCRs)’. They argue that DCRs are fixed in place (generally sited in neighbourhoods with a high incidence of street drug users and correspondingly high deprivation, crime and high negative health rates) to provide safe injection sites for persons with addictions. As local solutions, however, they also argue that DCRs, as they have been adopted in a growing number of countries and jurisdictions within countries, need to be seen as ‘globally-mobilized models of drug policy’ and positive public health practice.

V Vulnerable populations

There are many ways of thinking about vulnerability as it relates to health beyond biological vulnerability. In fact, most health geographers think about vulnerability as a social construction defined in terms of societal structures and individual behaviours. There is the vulnerability that results from being part of a group that is marginalized or discriminated against by a dominant societal group (e.g. immigrants or coming from a visible minority population). There is also the vulnerability that results from risky behaviours (e.g. substance abuse) or psycho-social or economic breakdowns (e.g. homelessness).

Recently, among health geographers, researchers from Canada have taken the lead in focusing on two vulnerable groups in particular: immigrant groups and Aboriginal peoples. Newbold and Simone (2015) focus on differences in disability rates between immigrants relative to the native-born in Canada, finding that new immigrants report lower rates of disability but also that within the immigrant population there are differences that deserve further exploration. Chadwick and Collins (2015) link self-reported mental health, social support availability and urban centre size in Canada. They find that social support availability is positively associated with small urban centres, both quantitatively and qualitatively. In an intensive study of South Korean immigrants to Canada, Wang and Kwak (2015) address transnational behaviour in seeking health services (e.g. importing medications from South Korea) and treatment (e.g. traveling to South Korea). In a study set in Ottawa, Subedi and Rosenberg (2016) examine highly skilled immigrants who are working in low-skilled service sector jobs (e.g. as taxi drivers) and the implications that this employment has for their physical and mental health.

In contrast to the Canadian research on immigrant groups, very much tied to the particularities of the point system used and a multi-cultural model of settlement, much of the recent research on immigrants (legal and illegal) in the United States focuses on Latino immigrants. In a highly original study where the goal was to develop an individual-based rurality measure and then apply it to Latino immigrants in North Florida, Mao et al. (2015) showed that their measure correlated well with social isolation and well-being in their study population.

Aboriginal peoples, housing and health are the themes of studies by Snyder and Wilson (2015) and Alaazi et al. (2015). Coincidentally, both studies are set in Winnipeg, Canada, although the two studies were carried out independently of each other. The former study argues that residential mobility which is mainly involuntary, linked to issues such as neighbourhood safety, results in negative health outcomes. The latter study looks at a housing intervention that addressed homelessness and mental health issues in a fashion that tried to take into account the culturally specific health, spiritual and lifestyle preferences of Aboriginal people, who make up a large percentage of the homeless population. Their key finding is that, despite relative satisfaction with the intervention, there was an adverse impact on a sense of place and home among Aboriginal participants in the study. Outside of urban areas, Daley et al. (2015) examine water, sanitation and public health risks in a remote Inuit community in the far north of Canada, notably the challenges that the Inuit face as they transition from a semi-nomadic hunting and gathering lifestyle to living in permanent settlements. Of importance in all of these studies is the tension that is generated when melding social and cultural values on health deriving from world views that do not fit easily with the dominant biomedical views of health, or with how these values and views are tied to the places where people live.

Homelessness and crime/safety also appear as themes in research on other vulnerable groups in other places. Waldbrook (2015) looks at how histories of homelessness affect health status among older people who now are living in secure housing situations. Using data sources from Australia, Astell-Burt et al. (2015a, 2015b) link crime to negative impacts on physical activity (using a multi-level cross-sectional analysis) and to negative impacts on mental health (using a longitudinal analysis) at the neighbourhood level. For Witten et al. (2015), the vulnerable group is inner-city children, with attention to their presence on inner city streets in relation to other marginalized groups. The children in the study demonstrate tremendous tolerance and resilience, but Witten et al. acknowledge the complex challenges that exist in trying to create inner-city neighbourhoods where the demands for healthy environments for children might conflict with the needs of other marginalized groups (e.g. intravenous drug users and their need for DRCs).

Emergent diseases, renewed racial tension and violence in urban America, and the waves of refugees seeking to find safe places in Europe, all point to the need for new ways of thinking about vulnerability. Hinchliffe (2015) and Hinchliffe and Craddock (2015) have argued for a ‘one world, one health approach’ as a framework to address the complexities among human, animal and ecological health as a response to emergent diseases. They and their colleagues follow up the call for a one world, one health approach in a series of highly thoughtful yet provocative papers (Craddock, 2015; Paige et al., 2015; Smith et al., 2015; Wallace et al., 2015). Herrick (2016) has suggested that health geographers need to take ‘contingency’ into account as a way of thinking about the unintended consequences resulting from the application of global policies at the local level in efforts to improve health. In what might now be seen as prescient papers that evoke the current political crises in Europe and the Black Lives Matters movement in the United States, Santana et al. (2015) and Rodriguez et al. (2015) have produced thought-provoking papers on the effects of economic and political crises. Santana et al. tie their analysis of the geography of suicide rates in Portugal to the economic crisis that has resulted in a breakdown in traditional geographic patterns and the development of new patterns based on rurality and material deprivation. Rodriguez et al. analyse data on the excess mortality rates of the Afro-American population between 1970 and 2004 to argue that, if excess deaths had not occurred, the effect on various presidential and state elections might have been different.

Thinking about outcomes such as suicide and excess deaths as the result of violence, DeVerteuil (2015) makes a strong case for conceptualizing violence as a public health issue. He argues for a three-dimensional framework distinguishing interpersonal violence, structural violence and intentional violence. Both theoretically and empirically, the one world, one health approach, geographical contingencies, violence as a public health issue and tying health geography to current economic and political crises open up new directions for health geography. What remains to be seen is whether health geographers will take up the challenges of incorporating these new ideas and the rapid changes taking place in our communities into their research.

VI Conclusions

By now, no one should be surprised that poverty, systematic racism, social exclusion, gender discrimination, and being very young or being very old – and particularly in combination – are correlated with negative health behaviours (e.g. excessive drinking, smoking, substance abuse, poor diets) and poor health outcomes (e.g. higher rates of heart disease, various types of cancers or obesity). What is missing are theoretical frameworks that provide clarity to our understanding of why those who experience such poverty, systemic racism, social exclusion, and/or gender discrimination and other forms of marginality are concentrated in particular parts of cities, why those parts of the cities are lacking in services, have the poorest quality transportation infrastructure, housing and schools, and whether living in those parts of the city have additive or cumulative effects or no effects at all on health outcomes and thresholds (i.e. how long it takes for the effects of living in a particular built environment to have an effect on a health outcome and whether the ‘dose-response’ relationships vary by any or all of the above). In a sense, we need more and better theoretical thinking and empirical research to find the answer to what Dorling (2015) has called ‘the mother of underlying causes – economic ranking and health inequality’. Or, to put it another way, we need to avoid falling into the neoliberal trap of focusing on the middle class and middle-class values, thereby losing sight of those who are truly in need and have the least resources to effect change to their health and their lives. We need to be sensitive to deeper critiques that avoid moral assumptions about how we define healthy bodies and neighbourhoods. We also need to take a stand with respect to those, both within our own ranks (as health geographers) and among health researchers in general, who have discovered health, space and place and, wittingly or unwittingly, are concluding – but arguably all too simplistically – that the built environment can determine people’s health.

In ignoring other parts of human geography where researchers are seeking to understand how poverty, systemic racism, social exclusion and/or gender discrimination are concentrated in particular parts of cities, health geographers are missing out on theoretical developments that might advance an understanding of the links between the health of people and the neighbourhoods in which they live. Are more cross-sectional studies, no matter how methodologically rigorous or innovative, or studies without more attention to theories of power, racism, discrimination, sexism and ageism going to lead to a better understanding of the role that the built environment plays in our health? At a time of growing inequalities at virtually every geographic scale and in every place, health geographers need to refocus their efforts on those individuals and groups who are the most vulnerable, even where governments, funding agencies, and our peer researchers have other agendas. It is time for health geographers to re-assess our old ideas, seek new ideas and avoid the traps of new determinisms.