INTRODUCTION: HEALTHSCAPES: HEALTH AND

PLACE AMONG AND BETWEEN DISCIPLINES

Erika Dyck and Christopher Fletcher

The essays in this book are concerned with the dynamic relationship between
health and place. In presenting this collection we explore a selection of historical
and cultural instances in which the multiple meanings of health and place inter-
sect. Some of these are rooted in materialist or physical interpretations; others
preface the role of sentiment and affect in place attachment and illness expe-

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rience; and others still delve into ontological and subjective engagements that
help us to understand how health and place connect with aspects of identity,
authenticity and sovereignty.
These concepts acquire texture through their material presence; for exam-
ple, the observable symptoms of disease, the institutions of medical practice,
or the political or geographical boundaries that delineate a place. In terms of
experience, behaviour is conditioned through health and illness and is further
mediated by social context, local practices and resources. These concepts are also
applied more abstractly; place becomes a plastic and ephemeral ingredient in
the formulation of memory, in attitudes that culminate in response to histori-
cal injustices, or where health is interpreted through beliefs and practices that
are profoundly shaped by ethno-cultural identities. Moving from a materialist
analysis to a more abstract conceptualization destabilizes our understandings of
health, place, and the interactions between the two, but also enriches our appre-
ciation of how people respond to illness in rooted and constructive ways.
As we began assembling this collection it became clear that the terms health
and place held different meanings across the disciplines. The subtle differences
in substantive meanings escalated as we tried to reach consensus on the kinds of
interpretive strategies necessary for developing more coherent definitions and
analytical frameworks. At that point the methodological and conceptual gulf
characterizing our respective disciplines emerged more clearly and encouraged
us to rethink. Just as it was difficult to find common language through which
historians and anthropologists discussed the role of place in health, it became
clear that the conceptual worlds we occupied had also introduced different
variables for defining these terms. For example, as we move from materialist

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2 Locating Health

analyses into the realm of interpreting cultural experiences we shift into different
methodological territory and the historians’ craft is sometimes stretched. Here
especially, historians draw benefits from interdisciplinary dialogue with medical
anthropologists, whose discipline offers a fundamentally different approach to
interpreting culture. Where historians cherish a degree of distance from their
subjects that time provides, anthropologists embrace a more intimate relation-
ship with their subjects through close interaction in the present and, by default,
in situ.
This book privileges historical and anthropological approaches to studying
health and medicine. Both disciplines are in the midst of a renewal of theoreti-
cal and methodological frameworks for critically analyzing the role of location,
place, or space in their work. For anthropologists fieldwork has always been
paramount in methods grounded in participant observation. Historians often
anchor their studies in locales, but temporal contexts frequently serve as the pri-
mary guide for evaluating subjects. Merely adding location to these disciplines
introduces new risks. Simply borrowing terminology or approaches from geog-
raphers, for example, potentially threatens the integrity of extant disciplines,

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rendering them undisciplined. The challenge, therefore, and one that we attempt
to address in this volume, is to develop fruitful interdisciplinary dialogue that
respects the integrity of respective disciplines but also adds a level of methodo-
logical complexity that enhances rather than dilutes each craft.

Health: Construct and Experience

Health is formed, nurtured, lived and denied in places. Throughout the world
people seek out places that provide the material conditions that foster physi-
cal health and that also offer spiritual, psychological, and existential solace. At
the same time, the human condition in its physical and existential dimensions
is profoundly shaped by health and disease. But, meanings ascribed to healthi-
ness and unhealthiness are individualized and engender different socio-cultural
responses. Medical anthropologist Allan Young has described a kind of language
used for this scenario: disease is a biological entity knowable through science
and acted upon by medicine, illness is the subjective experience of affliction by
disease, and sickness is the social context of disease and illness.1 An illness expe-
rience is closely tied to the physical and social ecology in which it occurs and,
in turn, it accrues social meanings, which are read into the body of the afflicted.
The presence of disease has a disturbing tendency to heighten the latent social
divisions among and between peoples.2 Disease may fracture the social body as
it challenges the individual. Health and place are therefore profoundly linked
constructs embedded in social practice with material repercussions.
Places are constructed in the literal sense of being built, organized and occu-
pied in ways that affect health. Where one lives, with whom, and with access to
 Introduction: Healthscapes 3

what resources, influences health outcomes. The physical designs of cities, access
to potable water, health services, food, and amenities contribute to, or detract
from, individual, familial and social wellbeing. Places are also constructed in a
figurative sense; they are produced through imagination, pieced together out of
experiences, mythologized through historical discourse and through the meto-
nymic roots of human heritage and lineage. Their meanings are manipulated and
incorporated into social, political and identity formation processes. These kinds
of attachments to place engender sentiments of social and political identity with
significant implications for health in a juridical and emotional sense. The quali-
ties of place are woven into notions of health in ways that localize health, disease
and medicine, while often simultaneously leaving intact powerful renderings of
scientific knowledge that relies upon a more universal discourse.
This conceptualization of the health-place dynamic forces us to confront
the potential contradiction between individualized health experiences and the
external characterization of health and disease categories. The former are highly
subjective positions that draw on physical states of wellbeing, inter-subjective
reflections on health and illness, social status and cultural dispositions. The latter

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emerge out of myriad factors tied to political, economic and scientific perspectives
that collectively define access to resources. Such resources include adequate food
supplies, medical services, housing and living conditions, economic opportunities,
and legal recourse for negotiating rights within a defined juridical setting. These
duplicitous conceptualizations of health thus have broad implications. Individuals
are subsumed into social, political and economic circumstances, which are in turn
historically situated and culturally constructed. Health, as a concept, therefore
becomes both an experience and a commodity at the heart of which lays a fun-
damental contradiction that undermines our ability to casually apply the terms
health and place with any expectation of a universal understanding.
The experience of illness is a challenge to individual autonomy and integ-
rity. In its confrontation with normative bodily conditions, illness lends itself
to unique insights onto the self and the world. Through sickness individuals
and groups may examine their situation vis-á-vis others. Bodily experience can
contribute to the realization of a critical social perspective on the production
of disease and health disparities within society. In this sense, illness and sick-
ness may illuminate the conditions under which disparities among and between
peoples and places is produced and maintained. Thus, individual states of suf-
fering extend outwards into social spaces affording unique perspectives on the
otherwise taken-for-granted conditions in which people live. Health disparities
are epiphenomena of other inequities and serve to orient attention to what may
be diffuse, historically embedded discrepancies. Health disparities are embodied
histories.3 The distribution of health and illness within regional, national and
global scales draws attention to the rooting of historical phenomena in the bod-
4 Locating Health

ies and lives of people. Examples are found close at hand; regions in which the
young leave for better fortunes elsewhere have the particular health profiles of
an aged population; tuberculosis is nearly eradicated in southern Canada yet still
widespread in the North; life expectancy among poor populations is less than
the wealthy almost everywhere. And so it goes.
One poignant illustration of this kind of interaction emerges out of the
apparent relationship among poverty, mental illness and homelessness. The
occupation of what we might consider minimal spaces by the poor, mentally ill
and destitute draws our attention to the rootedness of spatial notions in char-
acterizing the health of communities and households through social statistics.
The ‘vacant’ lot is ‘home’ to the homeless. Where a census tract consists of indi-
vidual or collective dwelling – households – many lives are lived in impermanent
spaces, rolled out at night, hostels and work camps, semi-serviced squatters
settlements and so on. Locating health among the myriad of bodies that flow
through these spaces speaks to coincident shaping of personhood, health and
place.4 As this example suggests, larger scales of political spatial reasoning may
subsume specific places.

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The relationship between health and place is recursive and inter-animating.
We see evidence of this in how particular forms of experience gather elements
of space together to form connotations of landscape/places/meanings. A simple
example is seen in the individual and collective representations through which
people are incorporated into a given locality and how that locality then serves
to shape their identity. The analogy of spatial processes to embodiment has been
made such that ‘... as places gather bodies in their midst in deeply enculturated
ways, so cultures conjoin bodies in concrete circumstances of emplacement.’5
Thus, building knowledge of the self that constitutes an experiential certainty of
sensation and awareness is much like the process of coming to see and feel a place
as familiar. Discursive, ritual and symbolic constructions serve to historicize a
given people’s place in the landscape and frame them within a moral economy of
the human place in the world.6 Just as the rhetoric of healthfulness may underpin
place ideologies; affliction uproots one from the everyday of place-based experi-
ence. Thus, in conventional language, healing can be understood as a ‘journey’ or
‘voyage’ from illness to health. It is a cultural and physical act of re-placement, a
process of finding new ground on which to stand.

Disciplinary Views
Health adds depth and texture to our understanding of the human condition,
in a manner that demands an application of a variety of intellectual tools. Fresh
attention to experience and authenticity amid trends of globalization draws us
toward the local as a space of home, comfort and familiar while still distinct
 Introduction: Healthscapes 5

from the experiences in other regions. While the temporal dimension of health
is an aspect that historians sometimes take for granted, anthropologists have
argued that history itself is a cultural phenomenon.7
The language of health and place is thereby challenged and enriched by
engaging in an interdisciplinary conversation that illustrates both the limits and
the elasticity of these approaches. Place is tantalizingly present in and absent
from both anthropology and history. Gradually this situation is changing, in
part, as a result of increased interdisciplinary dialogue. The influence of geogra-
phers, in particular, has drawn attention to a need to consider place as it affects
a number of developments, including scientific knowledge production, health
practices, disease transmission, as well as their historical interpretations.8
Historical analyses provide scholars with an opportunity to examine snapshots,
or developments frozen in time, ripe for sustained contextual analysis. Histories
of epidemics, medical professionalization, medical theories or illness narratives
have captured historical attention and allowed scholars to critically analyze and
contextualize such developments through a long lens. Time or temporality in part
defines the historians’ approach but this feature is also subsumed into the analysis,

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enabling historians to evaluate change over time. Historical reflection thus relies
on a degree of distancing between the observer and the observed.
In histories of health and medicine the temporal context is established at the
historian’s discretion, and often provides parameters for determining which con-
textual items are important for the analysis. Recent scholarship has identified
a spatial turn in historical writing, suggesting that much like analytical catego-
ries of race, gender, and class, place too demands consideration within historical
methodology.9 However, this spatial turn often operates at odds with attempts at
identifying universalizing trends, or ways of understanding knowledge produc-
tion, discipline, and identity formation. Nonetheless, as scholars in this volume
show, place – whether understood geographically, spatially, psychologically,
environmentally, or experientially – often interrupts the historical narrative and
therefore demands more sustained consideration as a methodological device.
Historical scholarship, whether part of the history of science and medicine or
social history of health, has struggled to interpret the role of place in its analyses.
Historiographically, we have often favoured methodological approaches that allow
us to broaden our studies, whether they involve top-down or bottom-up examina-
tions; place has often slipped off the analytical radar in an effort to minimize the
risk of producing a parochial study with seemingly limited value. Nonetheless,
recent political, economic and academic focus on the environment has given rise
to new scholarship that considers nature, environment, and geography as an actor
as opposed to an object. Some of those studies even go as far as to suggest a level
of geo-determinism, which gives priority to the environment over human actions.
Social and cultural historians and anthropologists may be reluctant to embrace
6 Locating Health

this trend wholeheartedly, but have begun to acknowledge a more complicated set
of interactions between humans and nature that condition culture.
This trend encourages linkages with geographers so that scholars might
examine more closely how place interacts with people, bodies, and ideas. As
David Livingstone has shown in a study of place and science, this intersection,
and sometimes collision, locates or situates ideas that are often connected to a
pursuit of universality.10 Health emerges as a fruitful area for investigation as it
allows interrogation at the level of bodies and experiences, areas that are shaped
by culture, environment, and time. Yet attempts to locate these experiences often
sit at odds with contemporaneous approaches, which seek to classify or diagnose
illnesses in a manner that erodes the significance of place. In spite of the tensions
that exist within this model, it serves to deepen our understanding of science
studies, medical theory and ultimately illness experiences when we consider
how local conditions mediate those developments. Adding place to the meth-
odological framework, therefore, allows scholars to anchor their studies in lived
experiences; it bridges theoretical perspectives with materialist investigations to
produce studies that are cognizant of the way that broader, more fluid and his-

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torically-contingent concepts, such as nationalism, authenticity, discipline and
authority condition individual experiences.
By contrast, anthropology tends to destabilize the notion of fixed categories,
whether that pertains to moments frozen in time, or diagnostic labels. Time,
region, illness, and health are all rendered contingent. It is common to situate
all meaning as constructed, publicly available, and interpretable by the astute
observer. Cultural meaning is omnipresent yet it remains contingent, indetermi-
nate and flexible. In this view, meanings acquire social lives, suggesting that they
are shared amongst people, but that they also shift over time and between places.
The meanings, however, are never fixed; they evolve. Part of that evolution relies
upon repetition whereby meanings gain traction but are also subject to being
reformulated, fractured and merged like blobs of mercury skittering across a table.
For a long time, anthropology conflated place as synonymous with culture
or incorporated it into scholarship as a formulaic ‘context’ segment without suf-
ficient theoretical or ethnographic interrogation, when it was considered at all.
In recent years this approach has shifted under the influence of some particu-
larly insightful scholarship about place and culture generally. For instance, Feld
and Basso’s collection of Senses of Place struck a cord with its nuanced ethnog-
raphy of human-place relations and the challenge it posed to scholars to think
with places rather than about them. For these authors, human communities are
intrinsically situated, and they acknowledge the power of place in the material,
cultural, cognitive and affective lives of people everywhere.
Building in this tradition, several prominent critical medical anthropologists
have focused on describing the social and cultural organization of power, which
 Introduction: Healthscapes 7

includes wealth and access to resources in the naturalization of the unhealthy

conditions of so many of the poor and disenfranchised.11 That work pushes the
boundaries of health conceptualizations beyond the characterization of disease
and its distribution into the social and political organization of inequity and
social suffering. In this view it is simply not enough to examine disease as a bio-
logical entity with spatial dimensions. Rather it is incumbent that we consider
the local environment along geographical and cultural axes and recognize its
formative influence in understanding healthiness and unhealthiness.

Ontology: Health and Place

Culturally shaped notions of the ‘self ’ are critical to understanding the diversity
of ways in which people organize their relations to place, and in how they concep-
tualize and experience health. Subjectivity, the experience of selfhood, is a form
of existential truth that defies the constructed nature of social life offering genu-
ine knowledge instead. Changes in one’s life circumstances are mitigated in the
first instance by subjective interpretations, which support or challenge an indi-

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vidual’s ontological security.12 Cross-culturally a common subjective expression
involves a deep symbolic, metaphorical and experiential association between the
body, bodily states and the landscape. The profoundly entrenched conviction
that one is part of a place and vice versa is especially explicit when people draw
their livelihoods directly from the land, such as among farmers, horticulturalists,
gatherers, hunters, or pastoralists. And yet as some scholars have pointed out,
the kind of subjectivity that is rooted in a place is historically reminiscent of ‘a
unique kind of human autonomy that seems to have all but disappeared in the
‘modern’, industrialized world.’13 The association between place and autonomy
has been theoretically conceptualized as a remnant of a bygone era, an artifact
of a pre-industrial period. In contrast, the modern form of self emerges out of
Enlightenment philosophy as an autonomous, discrete, self-interested and eco-
nomically rational one. This conceptualization in turn engenders new systems
of social and economic organization, and produces new forms of knowledge on
which self and society are reproduced.
The paradigmatic shift signaled by the Enlightenment and later established
during the Industrial Revolution created fundamental changes in the way that
science and technology acquired authority over the human condition. This
slow transition has had profound implications for human autonomy and thus
the significance of individual identities, experiences and places. In a sense, this
Enlightenment-based conceptualization of the self shook the individual free
from place. Within this framework western/industrial society became detached
from place while, somewhat ironically, laying the conditions for an unprece-
dented phase of territorial and imperial expansion. Perhaps within this tradition
we might also find the preconditions for globalization.
This model suggests that as individuals lose autonomy, they also lose a sense
of place. Moreover they are subsumed into a larger collective before re-emerging
as atomized parts of a new rational order that equates bodies with commodities,
machines, tools, or more generally, components of an organized system, whether
that is a system of medicine, justice, government, industry or production. Sci-
ence, medicine and technology flourish in this setting and acquire heightened
levels of authority and rationality while eroding place-based knowledge and
human autonomy. Measures of health too are subject to this kind of atomiza-
tion. Disease classifications, laboratory science, and medico-scientific knowledge
derive out of a desire to produce rational, placeless or universal, results. Health
or disease acquires status as an entity, removed from bodies and thus places. This
interpretive approach has had considerable currency in post-modern and post-
structuralist scholarship and yet, as this collection indicates, there is growing
resistance to the implications created by linking human agency or autonomy
with place. A more careful articulation of how place and experience co-mingle

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to produce agency is part of what this volume addresses.

Themes and Chapters

The places covered in this collection range geographically, from India to Nica-
ragua, to the United States, Serbia, the British Midlands, northern and western
Canada. While the jurisdictions change, the articles highlight the importance of
interrogating the nexus at which health and place interact to enrich our under-
standing of the social history of health and illness.
The collection begins with Helen Vallianatos’ anthropological study of
maternal health among poor women in India. These women negotiated chang-
ing health policies while the state entered a phase of national debt repayment at
the end of the 20th century that resulted in dramatic changes to funds available
for public health. By carefully teasing out strands of class or caste and gender
and situating them within a particular community context, Vallianatos shows
how identification with a specific place, along familial and geographical lines,
fundamentally affected a woman’s role in the community.
Jonathan Reinarz then offers an intriguing historical analysis situated at a
contested intersection of the fields of science, medicine, geography and his-
tory. By knitting together these various disciplinary threads, Reinarz identifies
a yet irreconcilable tension between place and organized medicine. Medicine,
he demonstrates, has increasingly embraced science as a legitimizing feature of
its practice, but scientific inquiry routinely measures its progress through the
discovery of universal principles, or absolutes. As a result, science in effect erases
 Introduction: Healthscapes 9

place in a pursuit of generalizations. Having identified a countercurrent, Reinarz

examines a community’s resistance to this modernizing impulse. Sasha Mullally
takes this discussion of modernity to a different place: the backwoods of Maine,
where she examines the biography of a peripatetic doctor figure. In particular she
illustrates how images of the region condition the doctor’s experiences, memo-
ries, and finally his celebrity status within the community. Ultimately, however,
the rural physician, untainted by accoutrements of modern medicine, emerges as
a somewhat static feature of the environment itself, embodying the stereotypes
of the region: rustic, simple, and rugged.
The next three authors provide an historical analysis of the health-place rela-
tionship with contributions that look carefully at how state policies influence
actions, which in turn feed into ideological commitments to health and medical
systems, along the axes of both research and delivery. Health becomes a concept
through which success or progress is evaluated within a sovereign state; belong-
ing to a nation, volunteering on behalf of national progress, or submitting a body
for an ideological cause, each of these actions become expressions of a political
identity which is understood through health. In these articles the temporal con-

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text of the Cold War emphasizes the ideological consequences of accepting a
western view of health and, subsequently, progress. Children’s bodies en masse,
as Mathew Smith tells us, become contested sites for measuring American pro-
gress as their science skills are compared with Soviet results. The offshoot of this
kind of brain race contributes to the pathologization of children’s attention and
activity into a medicalized disorder in need of psychiatric intervention. Health,
in this context, becomes the embodiment of sovereign ideological values, while
place expands to connote sentiments of nationalism, progress and superior
values. Identification with place, in this case the United States, becomes a short-
hand expression for a particular kind of health that is evaluated and maintained
through adherence to a particular ideology. This kind of discursive relationship
between ideology and place influences health care systems as well as medical
experiments, as Finkel then Smith and Mawdsley elaborate.
Geography, environment or nature itself, operates as a force bringing health
and disease. Moreover, belief or faith in the power of the environment to trans-
mit disease, or conversely to offer cure, depends on identification with particular
belief systems. In short, ethnic identity and aboriginality are examined in the
next two essays as concepts that flow from attitudes towards health, disease, and
healing. Belief in healing approaches forms part of an ideological position that
feeds into conceptualizations of identity and ethnic authenticity. Bringing health
and environment into sharp focus, Hugo De Burgos provides a nuanced exami-
nation of the delicate and dialectic relationship that exists between identity and
territory, which then produces a culturally contingent understanding of illness
and healing. In this way, De Burgos complicates the idea that place is a bordered,
10 Locating Health

sovereign entity by questioning the authenticity of ethnic identity and by inter-

rogating the notion of legitimately belonging to a particular place. Maureen
Lux’s article further explores these themes concerning the meanings of health
that are associated with particular environments, but does so by concentrating
on how western scientific medicine viewed particular environments as healthy
for specific bodies. While De Burgos examines a Veracruceños approach to dis-
ease construction and its treatment, Lux demonstrates how western medicine
also incorporated aspects of this approach, and indeed used it as an extension of
colonial practices of racial segregation and institutionalization in Canada.
The final two chapters explore health and environment, taking methodo-
logical cues from environmental studies and geography and applying them to
history and anthropology respectively. Liza Piper’s essay examines the interplay
of geography and disease in the Canadian north and uses case studies of cancer
and tuberculosis to show how over time these diseases came to be understood as
products of the environment, and their treatments were increasingly mediated
by geography. External factors profoundly shaped the health dynamics in the
nineteenth-century north through international traffic, travel, resource develop-

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ment and its associated environmental contamination and government policy.
Indeed health services in the Canadian north reflected a lack of coordination
and permanence that seemed to typify attitudes towards the northern commu-
nities – resource towns home to transient populations of mixed descent – a place
where the geographical environment dominated the flow of both parasites and
hosts while minimizing efforts to create institutionalized health centres. Marko
Zivkovic continues in this vein by examining the inter-relationships between
environment and health in post-Milošević Serbia, but in contrast with Piper,
Zivkovic examines places where the natural environment is coopted as a power-
ful symbol of ethnic health and identity. Zivkovic examines ‘places of power’,
which operate as symbolic tokens of identity along ideological, ethnic and
healthful lines. The places, some of which convey an image of health shrines,
also contain the trappings of a particular kind of Serbian identity, one that is a
product of a specific time, place and ‘ethno-eco’ identity.
Collectively we hope that the papers in this volume will bring new perspec-
tives to discussions on the recursive relationship between health and place, build
opportunities for novel interdisciplinary dialogue and introduce methodologi-
cal and conceptual avenues for future developments in this field. By locating our
studies we aim to bring complexity to an understanding of historical and current
cultural interactions. The essays in this volume provide new models for exploring
the dynamic relationships between health and place as lived phenomena in ways
that move beyond the use of static categorical terms.