jackson (2015)

Article

Triangulating health: Towarda practice of a political ecologyof health

Paul JacksonDartmouth College, USA

Abigail H. NeelyUniversity of Minnesota, USA

AbstractCalls for a political ecology of health have recently emerged in geography. This article builds on these tosuggest a practice of a political ecology of health by incorporating the insights of medical anthropology, STS,and history of medicine. Framed around three perspectives partial and situated knowledges, Marxist-feminist approaches, more-than-human geographies of health this article argues that incorporating theinsights of political ecology and cognate disciplines into the problems we investigate and the methods we usewill make for a stronger practice of a political ecology of health.

Keywordshealth, history of medicine, political ecology, medical anthropology, methods, social reproduction, STS

I Introduction

In recent years, a number of review articles have

debated the state of health geography. Written

by health geographers, they have noted a shift

frommedical to health geography, while calling

for a deeper engagement with critical geography

and social theory. Health geographers are not

alone in engaging with the question of health;

many geographers have turned to health to make

interventions into studies of culture, science,

(geo)politics, governance, and social theory. In

spite of this shared interest, these scholars have

yet to coalesce around a coherent set of ques-

tions, methods, and politics. One current of this

emerging research political ecology under-

stands health in terms of nature-society relation-

ships. In this article, we seek to build upon these

recent conversations, by placing the political

ecology of health in conversation with the cog-

nate disciplines of medical anthropology, his-

tory of medicine, and science and technology

studies (STS), as we sketch a practice of a polit-

ical ecology of health. To do so, we read our

arguments through two examples: Becky

Mansfields (2008a, 2008b) work on her

experience with natural childbirth in Ohio,

and Nancy Scheper-Hughess (1993) classic

anthropological work on childhood mortality,

maternal love, poverty, and ill health in Brazil.

Corresponding author:Abigail H. Neely, Department of Geography, Environmentand Society, University of Minnesota, 414 Social Sciences,267-19th Ave S, Minneapolis, MN 55455, USA.Email: [email protected]

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Science, place, and uneven geographies have

long been avenues of inquiry in political ecol-

ogy and health geography. Political ecology

understands these themes as problems, which

are relationally intertwined, produced over

time, inherently political, and always simulta-

neously material and symbolic. In addition,

political ecologists investigate these problems

through a mix of methods. It is precisely at

the intersection of these two components of

research designating problems and designing

methodologies that a practice of a political

ecology of health emerges. We argue that

rethinking health through the methodological

and theoretical traditions of political ecology

and related disciplines will enable geographers

to achieve novel insights into health, and to ask

and answer better questions. To open up possi-

bilities for a practice of a political ecology

of health, we propose triangulating different

approaches to health problems. To do so, we

have selected three perspectives or angles,

which emerge from political ecology, medical

anthropology, history of medicine, and STS:

understanding knowledge (including our own)

as partial and situated; using insights from

Marxist-feminist approaches; and incorporating

the non-human into our studies of human health.

We offer triangulation as a metaphor for our

practice; as these different perspectives or angles

converge, research subjects, places, problems,

and methods are illuminated. From the practice

we build here, we hope to open up the possibility

of integrating still more angles.

Through this integrative approachof triangula-

tion, our practice comes into focus. Briefly, we

argue the following. First, if knowledge is pro-

duced, circulated, and applied by scientists, bio-

medical doctors, and citizens, privileging some

voices over others, thenknowledge is situatedand

partial. Therefore, recognizing knowledge as par-

tial and situated is integral to developing the

methodologies through which to do our own

political ecologies of health. Accordingly, we,

as geographers, must deconstruct the knowledge

weproduce aswework to understand health. Sec-

ond, Marxist-feminist analyses help us articulate

the uneven production and reproduction of

healthy and unhealthy people both socially and

materially. They lay bare the politics around who

gets sick and who remains healthy, the provision

of health care, and the production, circulation,

and application of knowledge about health. Third

and finally, health and sickness are more-than-

human; they are an ecology. An attention to

non-human actors will help us understand the

processes that produce particular kinds of par-

tial and situated knowledge and reproduce

healthy and unhealthy people. Taken together,

these three perspectives help to articulate a

political ecological practice for health that uses

mixed methods, draws from critical theory, and

acknowledges its partiality.

As junior scholars trained in geography

along parallel tracks, and following from our

interest in partial knowledges and Marxist-

feminist approaches, we want to deliberately

situate our positions in the discipline in order to

render transparent our own practice of knowl-

edge production. Our similarities lie in a deep

engagement with debates about nature-society

relationships and political ecology, and an inter-

est in disciplines like STS and history. Our differ-

ences provide a wider breadth in thinking about

health: one of us works on the health politics of

urban environments in the global north, while the

other works on health in terms of rural, sociocul-

tural relations in the global south. During our

training, we benefited from productive debates

in political ecology; these debates inspired us

to embed our research on health in these lively

conversations. We are not alone, as increasingly

nature-society geographers for whom health

geography is not central to their professional

identity engage with questions about health (cf.

Braun, 2007; Guthman, 2011b; Keil, 2009;

Mansfield, 2008a; Sultana, 2012).

Health emerged as an object of study as a

problem from our research questions. As we

read classic works in health geography, however,

48 Progress in Human Geography 39(1)


we found ourselves wanting a more thorough

engagement with questions of nature-society

relations, study of local forms of knowledge, and

attention to broader political economy. We also

sought more insights into how we might conduct

research. Political ecology gave us this guidance

with a consistent suite of questions and methods.

Health geography (and particularly the reviews

we detail below) tends to focus on cataloging dif-

ferent strands of research and on breaking apart

health to study its constituent parts. By contrast,

debates in political ecology seek to integrate

methods and questions in order to engage with

the multi-faceted problems that emerge in the

subfield; they often focus on practice. As a result,

health and illness becomes one problem among

many to research. And, if health is a nature-

society question, then using the questions and

methods of political ecology is important

for articulating a practice of a political ecology

of health. In this article we offer a brief overview

of health geography and political ecologies of

health, introduce Mansfields and Scheper-

Hughess work on childbirth and childhood, and

provide insights from cognate disciplines as we

work through three different perspectives to

build a practice of a political ecology of health.

II Health geographies

In a recent special issue in theAnnals of the Asso-

ciation of American Geographers, editor Mei-Po

Kwan (2012) writes: geographies of health are

far too complex. She suggests that rather than

taking a single approach, health geography

should be organized thematically. In our own

reading of health geography, themes range from

infectious diseases (Mayer, 2000) to mental

health (Dear and Wolch, 1987; Parr, 1998), from

disability (Dorn and Laws, 1994; Park et al.,

1998) to chronic conditions (including disability)

(Dyck, 1995; Jones and Duncan, 1995; Moss and

Dyck, 2002), and from illness to well-being

(Kearns, 1993; Kearns and Gesler, 1998; Rich-

mond et al., 2005). To research and write about

these themes, health geographers use both quanti-

tative and qualitative methods. Because of our

expertise, however, we limit our intervention to

qualitative and critical approaches to understand-

ing physical health.2

In recent years, there have been a number of

health geography articles calling for various

shifts in inquiry while cataloging the state of

the subfield. Briefly, many scholars, like

Kearns and Moon (2002), have written about

a shift from medical to health geography,

noting the expansion of scholarship to include

more than simply disease. Scholars also note a

methodological focus on health in place and

research questions borne increasingly from a

critical, sociocultural theoretical position

(Kearns, 1993, 1997; Kearns and Moon,

2002; Parr, 2004; Philo, 2000, 2007). Critical

health geographers have pushed the subdisci-

pline by incorporating feminism, critical stud-

ies of biomedicine, and political economy into

their work. To complete this work, Dyck

(2003) pushes for the use of feminist methods

(and theory), specifically incorporating narra-

tive and focusing on women (as well as other

disadvantaged people) as research subjects

(see also Parr, 2004). Other geographers seek

to directly address biomedical knowledge, its

production, and its limits. For instance, Green-

hough (2011) seeks to bring together health

geography and the geography of bioscience

through ontological politics. Wallace (2009)

calls attention to the importance of global

political economy for peoples livelihoods,

looking at the intersection of neoliberal agri-

cultural practices in Asia, avian flu, and the sci-

ence that articulates the pandemic. Finally,

Sparke (forthcoming) offers a survey of the

relationships between geopolitics and global

health. In addition to these calls for more theo-

retical engagement, scholars like Fiona Smyth

advocate for more publically engaged scholar-

ship, noting the lack of research on the effec-

tiveness of policies to reduce the inequalities

that have an impact upon so many peoples

Jackson and Neely 49


lives (Smyth, 2008: 125). Taken together, this

is a rather unwieldy call for new developments.

III Political ecologies of health

Closer to our project here, a few scholars have

begun to call for interrogating health as a

nature-society question (Mansfield, 2008a),

calling for a political ecology of health and the

body (Guthman, 2011b; King, 2010; Mansfield,

2008b, 2011).3 They promote a rethinking and

rewriting and thereby re-practicing of

health by way of social nature or a biosocial

view (Mansfield, 2008a: 1019). King (2010: 50)

argues for a political ecology of health [to]

assist in explicating the links between social and

environmental systems, And Julie Guthman

and Becky Mansfield (2013: 487) have shown

that environments outside of bodies are inex-

tricably linked to those inside, calling on geo-

graphers to recognize the black-boxed . . .material, bio-chemical body as a key site of

interrogation. Together, these scholars seek to

answer questions about how sociocultural and

environmental contexts, political-economic

structures, and the materiality of life shape bod-

ies, biomedicine, health, health care, and the

experience of illness. To contribute to this emer-

ging subfield, belowwe use insights from polit-

ical ecology and related disciplines to sketch a

practice of a political ecology of health through

three perspectives.

With deep roots in studies of nature-society

relations, this emerging political ecology of

health has a decidedly different focus than

health geography. In political ecology, the

insights of critical geography, especially Marx-

ism, are constitutive of the problems scholars

seek to research and the methods they choose;

quite simply, without critical geography, there

would be no political ecology (cf. Escobar,

1999; Mann, 2009; Moore, 1993; Prudham,

2005; Smith, 1984). In addition, political ecolo-

gists pay particular attention to the history of the

places and people they study (cf. Cronon, 1991,

1995; Kosek, 2006; Moore, 1998), and the pol-

itics of environmental justice (cf. Bullard, 1990;

Heynen, 2003; Pulido, 1996; Sze, 2007). Fur-

ther, many political ecologists engage with the

material, incorporating understandings of bio-

physical processes into the questions they inves-

tigate and the methods they choose. These

scholars use remote sensing and participatory

GIS (McCusker and Weiner, 2003; Turner,

2003), soil sampling and vegetation analyses

(Blaikie and Brookfield, 1987; Forsyth, 1998;

Stott and Turner, 1998;Warren et al., 2001), and

ethnography, interviews, surveys, and archival

research (Bassett and Zueli, 2000; Escobar,

1998; Fairhead and Leach, 1996; McCarthy,

2006; Moore, 1993). This variety of methods

helps to bring out the voices of all people, as

well as non-human actors. Political ecology has

long worked across the divisions between

human and physical geography and between

qualitative and quantitative methods in order

to explain place-based phenomena in their

larger, global contexts. However, political ecol-

ogy has yet to fully incorporate questions about

the nature of healthy and unhealthy bodies. We

argue that it is precisely because of political

ecologys focus on human-environment rela-

tionships and its commitment to mixed methods

that it is well placed to interrogate health and the

body as problems that need to be situated, inter-

rogated with Marxism and feminism, and seen

as more-than-human.4

IV Healthy babies and hungrybabies

Building on work in political ecology that

examines the production of nature, we seek to

interrogate the (re)production of healthy and

unhealthy bodies in articulating our practice.

We offer as illustrative examples work by

BeckyMansfield (2008a, 2008b) on the nature

of childbirth in the USA, and place it in conver-

sation with the work of medical anthropologist

Nancy Scheper-Hughes (1993) on childhood



mortality in conditions of poverty in Brazil.

When placed in conversation, these two works

offer insight into the partiality of knowledge, the

value of a Marxist-feminist approach, and the

importance of the non-human in health. Specif-

ically, Mansfield interrogates her own experi-

ences of giving birth, meditating on what and

who makes childbirth natural. She uses auto-

ethnography along with textual analysis of pop-

ular and commonly-available parenting books.

So doing, she finds that childbirth becomes nat-

ural through the social relationships around

birth, rather than through awomans physiology.

Through her own practice,Mansfield argues that

it is unhelpful and unwise to separate the social

and the biological in natural childbirth. She

suggests that a biosocial framework will push

geographies of health to incorporate biophysical

aspects into ongoing work on social aspects.

Through this framework, she suggests what she

calls the political ecology of health and the

body, which posits human health dilemmas

as both an outcome of and an influence on

changing political economic conditions (Mans-

field, 2011: 415, original emphasis). Building on

this supposition in a later piece, Mansfield

reveals that microbes, chemicals, fish, family,

health, political economy, and biomedicine are

all part of a single story (Mansfield, 2011).

Indeed, this framework opens the door for incor-

porating sociocultural, political-economic, and

material aspects of health through a mixed-

methodological approach.

As a way to deepen Mansfields insights, we

return to Scheper-Hughess (1993) germinal

work on childhood mortality, Death Without

Weeping. Scheper-Hughes provides a specta-

cular analysis of life, hunger, mother love, and

child death in a resource-poor setting. She

begins by asking:

What . . .were the effects of chronic hunger, sick-ness, death, and loss on the ability to love, trust, have

faith, and keep it in the broadest sense of these

terms? If mother love is, as some bioevolutionary

and developmental psychologists as well as some

cultural feminists believe, a natural, or at least an

expectable, womanly script, what does it mean for

a woman for whom scarcity and death have made

that love frantic? (Scheper-Hughes, 1993: 15)

From the start, Scheper-Hughes grapples with

questions about what is natural, moving

beyond physical health to incorporate social

relations as embedded in global political econ-

omy. When Death Without Weeping is put

alongside Mansfields new work, the similari-

ties and differences are striking.5

More specific to questions of nature-society

interactions, Scheper-Hughes writes about

chronic malnutrition and a related local health

condition called nervoso, asking how hunger (a

nature-society problem) becomes sickness.

Methodologically, she combines an analysis of

the bodily impact of hunger as understood

through scientific (biomedical)workonmalnutri-

tion with an ethnographic analysis of how people

inBomJesus understand and experience nervoso.

She then places this in the context of a wider, glo-

bal political economy. So doing, she shows how

the population becomes prey to the medicaliza-

tion of their needs in a resource-poor area where

increases in income and access to food are impos-

sible and hunger becomes medicalized rather

than politicized (Scheper-Hughes, 1993: 169).

In her analysis, Scheper-Hughes has a profound

respect for how thosewho are suffering from ner-

voso articulate their illness; a condition she

argues is as much about poverty and disenfranch-

isement as it is about caloric deficit. Here,

Scheper-Hughes provides one answer to Kings

call for a political ecology of health that includes

attention to subaltern health narratives (King,

2010: 50). In her openness to biomedical and

non-biomedical articulations of health, as well

as her methodological dexterity, Scheper-Hughes

provides an example for understanding health as

a nature-society question.

Both Mansfield and Scheper-Hughes demon-

strate a nuanced engagement with questions of



health, the body, material contexts, and the social

relations in which they are embedded. We see

much overlap with political ecology in their

work. Mansfield interrogates her own use of

childbirth texts from the global north to situate

her experience. And to build a complete picture

of life and death and uncover subaltern health

narratives, Scheper-Hughes practices deep eth-

nography, adding layer after layer, from an his-

torical analysis of land tenure, to contemporary

hunger, to death and emotions, to the tactics of

survival. This layering reveals the underlying

global political-economic relations and structural

violence that lead to sickness and death in local

context (see also Farmer, 1999, 2005, 2006).

In spite of these examples and their methodo-

logical diversity, the question of how to do a

political ecology of health remains. This question

has the potential to yield conceptual paralysis.

Here again, Scheper-Hughes offers important

insight; with Margaret Lock, she warned:

We lack a precise vocabulary with which to deal

with mind-body-society interactions and so are

left suspended in hyphens . . . We are forced toresort to such fragmented concepts as the bio-

social, the psycho-somatic, the somato-social as

altogether feeble ways of expressing the myriad

ways in which the mind speaks through the body,

and the ways in which society is inscribed on the

expectant canvas of human flesh. (Scheper-

Hughes and Lock, 1987: 10, our emphasis)

Scheper-Hughes and Lock suggest that under-

standing health as a nature-society question will

require us to move beyond the hyphens to

think relationally. Indeed, a political ecology

of health requires that the different components

of the analysis come together from the begin-

ning and work together from problem to

research to writing. As a result, we are calling

for a more comprehensive and constitutive

approach to the political ecology of health that

understands health as situated, uneven, and his-

torically produced. Below we offer three per-

spectives distilled from history of medicine,

science and technology studies (STS), and med-

ical anthropology, which we believe will begin

to help us create a practice of a political ecology

of health. As a point of clarification, we propose

to move away from the paradigm of importing

theories from other disciplines and applying

them to the work we do as geographers. Instead,

we seek to internalize how other disciplines

inquire. So doing, we hope to promote and con-

duct research, as Sparke (forthcoming) says,

that stays attuned to adverse incorporation

across unequal life-and-death-worlds. We do

so in an effort to add to this burgeoning current

in geography, rather than to simply critique

what is missing. With the insights of related

disciplines (and those of geography), we seek

a distinct, more consistent, and more thought-

ful practice of a political ecology of health.

Through the practice we outline below, we hope

to contribute to ongoing efforts to develop a

methodological tool kit (Guthman and Mans-

field, 2013) that seeks to understand how some

bodies (and babies) become healthy while oth-

ers remain sick (and hungry). With this in mind,

we devote the rest of this article to thinking

through three perspectives or angles and the

methods employed to investigate them, in an

effort to triangulate a practice: how knowledge

is partial and situated; howMarxism and femin-

ism can be used as an analytical framework; and

how the non-human mediates (un)healthy

nature-society relationships.

V Toward a practice of a politicalecology of health

1 Angle one: partial and situatedknowledges

[N]atural childbirth is not just a worldview or set

of cultural ideas, but is instead a set of practices:

things women, their caregivers, and their wider

social networks do to make birth a normal, phy-

siological not risky, pathological experience.

(Mansfield, 2008b: 1094)



I want to show how medicine first begins to cap-

ture the imagination of people who, until quite

recently, interpreted their lives and their afflic-

tions and experienced their bodies in radically dif-

ferent ways. (Scheper-Hughes, 1993: 196)

To research and write political ecologies of

health requires us to start thinking critically

about how we know what we know about

health, to critically interrogate science and bio-

medicine.6 Geographers have long recognized

science (and knowledge more generally) as

partial and situated, even if this recognition has

not always shaped methodologies and practices.

STS has an impressive tradition of interrogating

the construction of knowledge and the produc-

tion of universality, scientific objects, concepts,

and discourses (cf. Bullard, 1990; Daston and

Galison, 2007; Haraway, 1991, 1997; Martin,

1991; Pulido, 1996). For our purposes here, we

focus on work by STS scholars, anthropologists,

and historians who see science as both socially

and relationally constructed. In particular (and

in anticipation of our third angle), we pay atten-

tion to scholars who incorporate the role of non-

humans in scientific knowledge formation.

Haraway (1988) wrote that all knowledge is

situated and partial, turning attention from

a single universal knowledge to a collection of

knowledges. Rather than seeing partiality as

a problem, Haraway argued that we should

embrace it, as it would make for more complete

scientific understanding and better objectivity.

She argued for a location, positioning, and situ-

ating, where partiality and not universality is the

condition of being heard to make rational

knowledge claims (Haraway, 1988: 589). For

Haraway, acknowledging partiality and recog-

nizing our own situatedness (race, class, gender,

institutional home, epistemological biases, and

geography) are part and parcel of knowledge

production. In creating a practice of a political

ecology of health, recognizing a partial objec-

tivity allows us to use scientific understandings

of biophysical aspects of health for some

insights, while pushing us to grapple with our

own positionality in, and the partiality of, the

knowledge we and others produce. In other

words, thinking critically about biomedical

knowledge is both a key question for investiga-

tion and an integral method for a political ecol-

ogy of health.

STS interrogates the production of scientific

knowledge through an analysis of both the prod-

ucts (or objects) of that knowledge and the pro-

cesses by which the knowledge is formulated.

To do this, scholars use a mix of methods from

collecting and critically interrogating docu-

ments to interviews and ethnography. They see

knowledge as structured and produced through

social relationships among scientists, between

doctors and patients and find evidence of those

relationships in these documents. These scho-

lars triangulate their sources and use (and pro-

duce) social theory to analyze their empirical

data. These methods produce scholarship that

varies from narrative accounts to theoretical

interventions to case studies. Both Mansfields

and Scheper-Hughess work incorporate lessons

from STS, critically evaluating knowledge and

placing it in conversation with embodied experi-

ence, cultural interpretations, and broader

political-economic contexts. Similarly, political

ecologists who engagewith STS have shown that

there is more to study when it comes to knowl-

edge than production: circulation and application

matter too (Goldman and Turner, 2011). If we are

to take seriously the idea that knowledge is par-

tial and situated, we should also think about what

happens when that knowledge leaves the hands

(andminds) of the people who create it; we ought

to focus on its application.

The history of medicine shows how knowl-

edge and ideas are formed over time and in

place. Indeed, history can be an important

method to show how knowledge, medicine, and

science are produced and situated. Three brief

examples illustrate that knowledge is partial,

contested, historically contingent, and in con-

versation with other ways of understanding. In

Colonizing the Body, David Arnold (1993)



reveals that colonial medicine was central to the

colonial political project, incorporating subaltern

studies and Gramscian ideas about hegemony.

Steven Epsteins Impure Science (1996) investi-

gates how AIDS activists shaped the production

of knowledge in the early years of the epidemic

in US cities, transforming the practice of early

AIDS research. Warwick Andersons (2008) The

Collectors of Lost Souls investigates how places

are connected through the circulation of knowl-

edge and people, as he follows Kuru/prion scien-

tists from field to laboratory to international

meeting. These scholars reveal that the historical

and geographic contexts in which knowledge is

produced, circulated, and applied shapes that

knowledge and its use. Significantly, in focusing

on colonialism, activism, and appropriation,

these scholars detail how power differences

shape the production and circulation of

knowledge.

Historians of medicine use a combination of

archival sources, published sources, and oral

histories to situate their work in time and place.

Their analytical methods include the triangula-

tion of sources, textual analysis, and the acts

of writing and revising. Significantly, archives

are not perfect records of the past; some voices

are better preserved than others. As a result,

even though historians work to incorporate sub-

altern voices and the daily lives of healthy and

unhealthy people, their investigations of knowl-

edge tend to focus on production and circula-

tion, rather than application.

To map out the global unevenness of knowl-

edge, geographers can learn from medical

anthropologists who interrogate the processes

of knowledge production, circulation, and

application. For example, anthropologists have

analyzed: how medicine becomes a system of

signs and symbols (Kleinman, 1988); how

training produces medical expertise (Good,

1998; Wendland, 2010); how doctors and

patients negotiate this expertise (Kleinman,

1980; Lazarus, 1988); and how patients experi-

ence ill health and medicine (Kleinman, 1988).

They also address scarcity within global polit-

ical economy. For instance, Wendland (2010)

investigates how global political-economic

structures shape underfunded medical training

in Malawi, revealing that medical students

become politicized when they seek to apply their

new-found medical knowledge with insufficient

resources. Additionally, many medical anthro-

pologists incorporate understandings of health

for people who are not medical experts. This

reveals the mismatch between the experience of

bodily illness and biomedical categories. As

touched on above, Scheper-Hughes (1993)

shows that local understandings of nervoso

revealed as much about poverty and uncertainty

as they did about the biophysical ramifications

of malnutrition. By making health about more

than simply biomedical illness, medical anthro-

pologists employ both scientific knowledge and

ethnographic methods to show that knowledge

about illness and health is always situated. In

addition, ethnography, as an analytical method,

allows scholars to incorporate and analyze non-

biomedical understandings of what harms and

what heals (Feierman and Janzen, 1992; Living-

ston, 2005). Through this approach, anthropolo-

gists provide rich and detailed accounts of

people and knowledge as situated in particular

times and places.

Together, scholars from STS, history of medi-

cine, and anthropology offer tools for a practice

of a political ecology of health. With attention to

social relationships, place, and time, as understood

through theuseof biomedicine, documents, ethno-

graphy, and interviews, these scholars uncover

how knowledge is produced, circulated, and

applied in specific situations. Significantly, this

work reminds us to be cognizant of the ways in

which we produce knowledge, remembering that

our geographies of health are both partial and situ-

ated, and that their circulationandapplicationmat-

ter. It is here that the idea of partial and situated

knowledge turns from question tomethod in polit-

ical ecologies of health. In order to recognize this

shift, we suggest creating methodologies that



include knowledges from different subject posi-

tions and writing self-consciously about the pro-

duction of our own work. These lessons remain

at the forefront aswe integrate our next twoangles.

2 Angle two: Marxist-feminist approaches

This was my first concrete hint that maybe there

was something else going on during the first birth,

something that wasnt all about my body (and I

was very aware of how my choices were highly

constrained by what was available). (Mansfield,

2008a: 10171018)

In the place of the poetics of motherhood, I refer

to the pragmatics of motherhood, for, to para-

phrase Marx, these shantytown women create

their own culture, but they do not create it just

as they please or under circumstances chosen by

themselves. (Scheper-Hughes, 1993: 341342)

Marxism and feminism offer tools to unpack the

power relations and uneven geographies that

circumscribe and infuse partial and situated

knowledges. Further, questions animated by

Marxism and critiques of political economy

have long been central to critical geography and

political ecology. Likewise, feminism has influ-

enced lines of inquiry in many subfields with its

attention to inequalities and its incorporation of

voices of the marginalized. By incorporating

both Marxism and feminism into political ecol-

ogies of health, we can ground the practice of

research in a deep engagement with materia-

lity and politics. Further, only when feminism

fully incorporates intersectionality can the int-

eractions of systems of discrimination (gender,

race, sexuality, indigeneity, and so on) be

parsed in a political ecology of health. Broadly,

Marxist-feminist research investigates inequality

as embodied through gender and capital. So

doing, it reveals how uneven global political-

economic processes manifest in bodies which are

embedded in local social and cultural contexts.

This insight strengthens research into health,

understandings of health, and access to health

care. Further, And Haraway reminds us that

knowledge production cannot be separated from

these processes.

Medical anthropologists assist here. In part

due to the subfields deep commitment to the

particularities of place as located in global cir-

culations of capital, development, drugs, and

expertise (cf. Hayden, 2003; Nguyen, 2010;

Sunder Rajan, 2006; Wendland, 2010), they

recognize that political-economic structures

shape how people experience and understand

health. Anthropologists use the concept of struc-

tural violence to reveal how uneven global

political-economic structures do real, corporeal

harm to disempowered individuals (Farmer,

1999, 2005, 2006; Ong and Collier, 2005;

Sunder Rajan, 2006). For these scholars, the glo-

bal and local are inextricably linked, as they bring

together people like HIV-positive activists in

West Africa and Paris (Nguyen, 2010), through

things like antiretroviral (ARV) pharmaceutical

products (Craddock, 2007; Lakoff, 2008). In fact,

these global-local connections are so important

that their absence is noteworthy. Joao Biehl

(2005) gives us Vita, a last-chance home for the

ill and poor, the socially abandoned. Here, people

live so far on the margin that they only become

fully part of society through their long, painful

decline and death.A similar commitment to place

and a close attention to everyday life embedded in

uneven political economy can strengthen a prac-

tice of a political ecology of health.

Place and political economy have long been

of central concern in geography. In his book

Love in the Time of AIDS, Mark Hunter (2010)

examines the impact of political economy

through the geography of intimacy and the

materiality of everyday sex in South Africa. His

attention to love, gender, relationships, family,

households, livelihoods, and everyday life

shows how political-economic structures shape

the choices people make about their most inti-

mate relationships. These decisions, as Hunter

reveals, then place their health at the gravest

risk. Likewise, Craddock (2000) reveals that



class structures are embedded in racialized built

environments that shape how infectious dis-

eases spread, who gets sick, and who determines

policy. In this work, the emphasis on political

economy and class is strengthened through ana-

lytics of race, gender, and sexuality. To bring

these together, we echo Valentines (2007) call

for the incorporation of intersectional analysis

and lived experience in feminist geography,7

including it in the practice of a political ecology

of health. Feminist health geographers (Dyck

et al., 2001) offer additional insight to build upon

long-standing feminist critiques of Marxist polit-

ical economy (Gibson-Graham, 1996; McDo-

well, 1992; Rose, 1993), implemented through

qualitative and self-reflexive methodologies.

To bring together Marxist attention to scar-

city, global political economy, and everyday

life with the personal-is-political insights of

feminism, we offer the concept of social repro-

duction (Mitchell et al., 2004). FollowingMans-

fields and Scheper-Hughess work, we return

to the question of childbirth. In the conclusion

of Limits to Capital, Harvey (2006) proposes a

synthesis of feminist and Marxist theory and

suggests a different material foundation for a

critique of capitalism. He writes, The starting

point . . . is not the commodity, but a simpleevent the birth of a working class child

(Harvey, 2006: 447). Harvey proposes to begin

his Marxist-feminist critique at the birth of the

worker. Butler (2010: 14) similarly grounds her

notion of precarity in birth, writing precar-

iousness is coextensive with birth itself. For

Butler, precarity is an elementary condition of

human life, refering to the shared material basis

of survival. Survival depends on social rela-

tions, where all life (including illness) is social

and should be understood (and reproduced) as

such. In a recent talk, Graeber (2012) brings

together Harveys insights, feminism, and poli-

tics, but looks to break the associations between

birth and biology, and social reproduction. He

sees social reproduction as the production of

human beings . . . producing each other . . .

[that] cannot be reduced to standard categories

of political economy. In other words, all people

are constantly socially reproduced regardless

of time of life relationally. Because we are

concerned with the geographic processes that

produce and reproduce healthy (and unhealthy)

bodies, interrogating social reproduction is

important for our practice.

While social reproduction has been studied in

geography, it has not been taken up in discus-

sions about health. Yet, Cindi Katz (2001)

pointed to health as an important aspect of

social reproduction long ago:

At its most basic, [social reproduction] hinges

upon the biological reproduction of the labor force,

both generationally and on a daily basis, through

the acquisition and distribution of the means of

existence, including food, shelter, clothing, and

health care. (Katz, 2001: 711, our emphasis)

Katz offers a Marxist-feminist mode of inquiry

that pays attention to daily and long-term prac-

tices of survival, beyond birth. In this, we hear

echoes ofScheper-Hughesswork.Here, the birth

of the worker and the daily (re)production of the

body, aswell as the intertwining of different types

of expertise and cultural practices, can only be

understood in particular sites. This place-based

analysis (a hallmark of political ecology and

health geography) helps us to explain the mate-

rial, social, cultural, and knowledge-related

aspects of social reproduction.

Following this example, we see a Marxist-

feminist approach pushing forward our under-

standing of health as situated and partial. Turning

again to Katz, we see that Social reproduction is

the fleshy, messy, and indeterminate stuff of

everyday life (Katz, 2001: 711). It is integral to

everyday life, to the production of healthy work-

ers, and to the production of healthy people. By

contrast, unhealthy bodies are constructed as

unproductive, as not yet fully human, as insuffi-

ciently socially reproduced. Using a Marxist-

feminist approach shows us that sick bodies

are just as fleshy, messy, indeterminate, and



embedded in wider political-economic processes

as healthy workers. Turning again to Haraway

(1991), we see bodies as suffused by capital,

patriarchy, technology, and the non-human, and

as shaped by particular (partial) regimes of

knowledge. Together, these scholars reveal that

health is situated in everyday realities that vary

across time and space. In other words, all bodies

are partial, situated, and inescapably producing

each other.

Serendipitously, our examples of Mansfields

and Scheper-Hughess work on birth and child-

hood dovetail neatly with some of the core

insights of social reproduction and Marxist-

feminist approaches more broadly. Further, this

framework helps us to make sense of the differ-

ences and similarities between the two works

Mansfield offers an active political choice of

natural childbirth (highlighting the personal-is-

political methods of feminist scholarship) and

Scheper-Hughes gives us an account of the lim-

ited choices of mothers in poverty-stricken Bom

Jesus (highlighting the importance of Marxist

political economy). In both examples, the ques-

tion of who is successfully socially reproduced

and how (who is healthy) is as much about

political-economic structures as it is about socio-

cultural context. A Marxist-feminist approach

allows one to place these different cases in con-

versation, investigating the intertwined processes

of the social reproduction of health as embedded,

situated, partial, personal, and always historically

and geographically specific.

3 Angle three: more-than-humangeographies

How do we avoid biological determinism or naive

notions regarding the independence of nature

without falling into the trap of denying the exis-

tence and significance of the biological body?

(Mansfield, 2008a: 1015)

They were the retirantes (driven or expulsed

ones) and flagelados (the afflicted) who crossed

the barren wastelands that even birds and small

mammals had deserted only to find when they

arrived finally at the sugar plantations of Bom

Jesus that the local waters were spoiled: brack-

ish, salty, putrid, and contaminated by microbes

and chemical pollutants. Their response has been

angry. (Scheper-Hughes, 1993: 68)

If health is a nature-society question, the answer

to which is situated and shaped by feminist and

Marxist politics, then how do we understand and

interrogate nature? How do we incorporate the

non-human into our political ecologies of health?

We begin by examining how the non-human

unevenly affects human bodies and how non-

human agents make people sick (or healthy). In

doing so, we strive to pay attention to the net-

works of social relations in which non-human

actors are embedded (Castree, 2002). Building

on our last two angles, we focus our analysis on

the decentered body, or on the body as a site of

accumulation, as socially (re)produced (Guth-

man, 2011a). To do so,we interrogate individuals

(and their bodies) in relation to other people,

including scientists and members of formalized

lay groups (knowledge producers).We also focus

on bodies in relation to non-human actors such as

bacteria, genetics, buildings, and toxins.

The biophysical, biochemical, and genetic

processes of health and ill health provide a con-

undrum for geographers: how do we incorporate

expertise and claims about more-than-human

illness, the experiences of sick people, and the

bacteria, viruses, future generations, and toxic

environments they come into contact with into

our geographies of health? Thanks to resources

like PubMed, health geographers in the USA,

regardless of institutional home, have access

to cutting-edge biomedical research; we all

have the opportunity to use science to under-

stand the non-human if we choose. That said,

if we are to use biomedical science as a way

to understand how the non-human interacts with

human bodies, we should be as critical about the

science as we are about interviews and archival

documents. We are compelled to recognize the



partiality and situatedness of the scientific

knowledge we build upon. Here we come full

circle back to our first question, and here again

political ecology, with its mix of methods, pro-

vides a guide.

Political ecologists have long engaged with

environmental historians who write about the

intersection of health and environment. These

historians offer a model for more-than-human

geographies of health. Gregg Mitmans (2007)

work on allergies and asthma, Linda Nashs

(2006) work on pesticides, farming, and farm

workers, and Helen Tilleys (2004) work on try-

panosomiasis show how health and ill health are

produced simultaneously by people and by their

environments. These authors also reveal that

non-human nature plays as big and as unpredict-

able a role in shaping human health as people do.

They do so through attention to time and place,

the use of archival sources, and the mobilization

of scientific knowledge, past and present.

A key publication at the intersection of medi-

cine, science, history, health, and environment is

the special issue of Osiris, Landscapes of Expo-

sure (Mitman et al., 2004), which opens up ques-

tions about health and the non-human. In the

introduction, Mitman et al. offer three key

themes which overlap with the work of geogra-

phers: scale, materiality, and uncertainty. Geo-

graphers who research the politics around

highly infectious disease a more-than-human

world that besieges the body have taken on

many of these themes (Ali and Keil, 2008;

Cooper, 2006; Ingram, 2005). For example,

Bruce Braun (2007: 14) shows us that a body is

embedded in a chaotic and unpredictable mole-

cular world [and is] understood in terms of a gen-

eral economy of exchange and circulation,

haunted by the specter of newly emerging or still

unspecifiable risks. For Braun, uncertainty runs

deep and scalar relationships from the molecular

to the global shape the materiality of health.

Braun (2007), along with Guthman and

Mansfield (2013), brings us back to the body.

Building on our second question, we ponder

how (socially reproduced) bodies can help us

understand health as more-than-human (Braun,

2005). Over the last 40 years, the body has been

well studied across the social sciences and

humanities, particularly in anthropology. As

such, it withstands a single definition; it has

been framed as the body multiple (Callard,

1998; Harvey, 1998; Mol, 2002) and the cyborg

(Haraway, 1991), while others have looked

beyond the body proper (Lock and Farquhar,

2007). In 1995, Harvey and Haraway discussed

bodies-in-the-making, along with nature-in-

the-making, stressing accumulation and social

reproduction (Harvey and Haraway, 1995:

515). They showed that open and porous bod-

ily accumulations can and do include social and

power relations, toxins, bacteria, food, repre-

sentations, labor relations, and so on (Harvey,

1998; Harvey and Haraway, 1995). Moving the

discussion further through the frame of environ-

mental epigenetics, Guthman and Mansfield

(2013) unpack the biochemical body to examine

how the environment actually comes into the

body. Together, these scholars show that bodies

are never singular nor outside of environments,

and that human and non-human relationships are

key in (re)producing (un)healthy bodies.

As an outstanding example of bodies-in-

nature, we turn to the work of STS scholar

Michelle Murphy. In her book, Sick Building

Syndrome and the Problem of Uncertainty,

Murphy (2006) investigates sick building

syndrome, asking how buildings affect bodies.

She uses the concepts of assemblages, materia-

lization, and regimes of perceptibility to show

the porous boundaries between bodies and the

environment. For Murphy, bodies are materia-

lized otherwise, in relation to the myriad

non-human actors around and within them.

Secretaries, air-conditioning, dust-mites, and

carpeting form assemblages located in work-

places where the very idea of being sick is

contested. In this account, personal knowledge

of illness becomes a method for political mobi-

lization. In Murphys book, all three of the



questionswe haveworked through come together:

bodies are materialized through their interactions

with non-human actors in a broader political-

economic context; knowledge of health and the

role of the non-human is produced, partial, and

situated; and women vocalize the sickness and

pain that pervades their everyday lives.

Finally, we seek the incorporation of the non-

human into our geographies of health because

understanding health as more-than-human blurs

the boundaries between people and their envir-

onments. This then forces us to take seriously

both the materiality of health and how health

materializes otherwise. To do so, we need a

suite of methods that help give voice to non-

human (as well as human) actors. And, as we

have described in detail above, political ecol-

ogy, medical anthropology, STS, and environ-

mental history all use mixed methodological

approaches that include (the critical use of) sci-

ence and qualitative data. By triangulating these

perspectives and weaving together these various

scholarly approaches, we offer a distinct prac-

tice of a political ecology of health, one that

allows our questions and methods to engage in

research that grapples with uncertainty, values

the disempowered, and positions each human

birth in the vortex of genetics and imperialism,

toxins and patriarchy, microbes and capital, and

natures and knowledges.

VI Conclusion: triangulating health

While the separation of these three angles is

useful analytically, it is important to remember

that they intersect and build. As our perspective

about the non-human reveals, careful interroga-

tion of the production and circulation of

knowledge is important methodologically (in

assessing non-human agency), in addition to

being an important line of inquiry; questions

and methods are not so neatly divided. Further,

if we are to take a Marxist-feminist approach to

understanding health and the body, social repro-

duction reminds us that the physical act of

childbirth is merely the beginning. If a baby is

to become a healthy child (or even to become

a child at all), her process of becoming requires

continuous and collective support. As more and

more scholars begin to work on a political ecol-

ogy of health, we hope that the angles we have

sketched here partial and situated knowledges,

Marxist-feminist approaches, more-than-human

geographies and the methodological lessons

from political ecology, STS, history of science,

and medical anthropology we offer can help

guide this burgeoning field.

We conclude by returning to three important

(and yet unresolved) problems for geographical

research on health raised by Scheper-Hughes

and Mansfield: health, reproduction, and bod-

ies. We believe that the practice we have trian-

gulated here offers possibilities for exploring

these problems. First, we turn to health: in her

recent work on obesity, Guthman (2011b) levels

a devastating critique against healthism, a

moral ideology that constructs health as neutral,

positive, and an individuals responsibility (see

also Metzl and Kirkland, 2010). So doing, she

reveals health as an inherently political concept,

that if left unproblematized has the potential to

hinder the practice of a political ecology of

health. Second, reproduction: Guthman and

Mansfield (2013) question the intergenerational

effects of environments, by focusing on how

environmental toxins shape fetal development

and phenotype plasticity. So doing, they build

on Guthmans work on health and healthism

to complicate our understandings of future gen-

erations. To this, we would add that the repro-

duction of healthy and unhealthy bodies is

also always an exercise in collective social

reproduction. Third and finally, bodies:

Guthman and Mansfield (2013) also seek to

understand theporous boundaries betweenbodies

and environments through epigenetics in order to

explore bodies as nature-society relationships.

They then build on this insight toward practice

arguing that body-environmental epigenetic

interactions invite us to re-think the assumptions



of the [geographic methodological] tool kit

(Guthman and Mansfield, 2013: 487). Guthman

and Mansfield, along with other political ecolo-

gists, have taken steps to begin to outline a toolkit

to show that bodies are just as uneven and situated

as geographies. They have shown that formu-

lating a distinct practice of a political ecology

of health requires us to understand health, the

environment, and the body as neither predeter-

mined nor black-boxed. Recognizing knowledge

as partial and situated, using the lessons of

Marxist-feminist approaches, and incorporating

the non-human into our political ecologies of

health help us to do just that.

The practice of a political ecology of health

that we propose grounded, nuanced, situated,

and employing multi-method research helps

trace why some babies flourish while others

do not, in order to lay bare the unevenness of

healthy and hungry futures. Indeed, as Mans-

field and Scheper-Hughes have shown, knowl-

edge about health is situated and partial,

structured by class and gender, and shaped by

a more-than-human world. Through their exam-

ple, how we conduct critical research then

becomes a problem we can work to solve; the

practice we have sketched above is a step in this

direction. In triangulating a practice of a politi-

cal ecology of health through these three

perspectives, we echo the growing call that

health is inherently a nature-society relation-

ship (Mansfield, 2008a: 1015). Yet we recog-

nize that how nature-society relations become

ingrained in the questions and methods of geo-

graphies of health remains open. We have pro-

posed three guiding perspectives that begin to

triangulate a political ecology of health. In this,

we have sought to offer a practice. There are, of

course, other perspectives we could have cho-

sen, the most striking of which is the question

of health itself, what it means, whom it is for.

Howmight this practice contribute to novel con-

ceptions of health, both grounded and proble-

matized through geography? Answering this

requires a collective contribution; this article,

with its focus on research problems, methods,

and practice, represents our initial work toward

that collective end. We hope that others will add

to this (necessarily) partial intervention; after

all, at its most basic, scholarship is about asking

the right questions and using the best methods to

answer them.

Acknowledgments:

Were grateful to the participants of the University of

Minnesota Department of Geography, Environment

and Societys spring 2011 seminar in critical

approaches to health for helping us think through

many of the ideas that ended up in this article. Wed

also like to thank three anonymous reviewers for

their feedback; this paper is stronger for it.

Funding

This research received no specific grant from any

funding agency in the public, commercial, or not-

for-profit sectors.

Notes

1. Following convention, the authors are listed alphabeti-

cally even though they contributed equally to the article.

2. It is precisely in the mix of qualitative and quantitative

approaches that health geography has much to offer

methodologically to a political ecology of health

(Brown et al., 2009).

3. As far as we can tell, the political ecology of disease

was first used by Turshen (1977, 1984).

4. For those readers unfamiliar with political ecology,

there are a number of excellent overviews and reviews

of the subfield. For example, see Robbins, (2012),

Walker (2005, 2006, 2007), and Zimmerer (2004,

2006, 2007).

5. We acknowledge that Scheper-Hughes has a markedly

different project than Mansfield, one which includes

multiple years of ethnographic research and comes to

light in a 500-page book.6. We acknowledge that biomedicine is not the only way

we know health.

7. For an intersectional analysis in feminist political ecol-

ogy, see Mollett and Faria (2013).

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