Article

Triangulating health: Toward

a practice of a political ecology
of health

Progress in Human Geography

2015, Vol. 39(1) 4764
The Author(s) 2014
Reprints and permission:
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DOI: 10.1177/0309132513518832
phg.sagepub.com

Paul Jackson
Dartmouth College, USA

Abigail H. Neely
University of Minnesota, USA

Abstract
Calls for a political ecology of health have recently emerged in geography. This article builds on these to
suggest 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, Marxistfeminist approaches, more-than-human geographies of health this article argues that incorporating the
insights of political ecology and cognate disciplines into the problems we investigate and the methods we use
will make for a stronger practice of a political ecology of health.
Keywords
health, 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
from medical 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 questions, methods, and politics. One current of this
emerging research political ecology understands health in terms of nature-society relationships. In this article, we seek to build upon these
recent conversations, by placing the political

ecology of health in conversation with the cognate disciplines of medical anthropology, history of medicine, and science and technology
studies (STS), as we sketch a practice of a political 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, Environment
and Society, University of Minnesota, 414 Social Sciences,
267-19th Ave S, Minneapolis, MN 55455, USA.
Email: ahneely@umn.edu

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Science, place, and uneven geographies have

long been avenues of inquiry in political ecology and health geography. Political ecology
understands these themes as problems, which
are relationally intertwined, produced over
time, inherently political, and always simultaneously 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 possibilities 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 ST S:
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 approach of triangulation, our practice comes into focus. Briefly, we
argue the following. First, if knowledge is produced, circulated, and applied by scientists, biomedical doctors, and citizens, privileging some
voices over others, then knowledge is situated and
partial. Therefore, recognizing knowledge as partial 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

we produce as we work to understand health. Second, 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-thanhuman; they are an ecology. An attention to
non-human actors will help us understand the
processes that produce particular kinds of partial 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 Marxistfeminist approaches, we want to deliberately
situate our positions in the discipline in order to
render transparent our own practice of knowledge production. Our similarities lie in a deep
engagement with debates about nature-society
relationships and political ecology, and an interest in disciplines like STS and history. Our differences 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, sociocultural 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,

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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 different 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 naturesociety 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 ScheperHughess 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 the Annals of the Association 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; Richmond et al., 2005). To research and write about

these themes, health geographers use both quantitative and qualitative methods. Because of our
expertise, however, we limit our intervention to
qualitative and critical approaches to understanding 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 subdiscipline by incorporating feminism, critical studies 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 narrative 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, Greenhough (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 agricultural practices in Asia, avian flu, and the science 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 theoretical engagement, scholars like Fiona Smyth
advocate for more publically engaged scholarship, noting the lack of research on the effectiveness of policies to reduce the inequalities
that have an impact upon so many peoples

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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 inextricably linked to those inside, calling on geographers 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 bodies, biomedicine, health, health care, and the
experience of illness. To contribute to this emerging subfield, below we use insights from political 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 Marxism, 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 ecologists pay particular attention to the history of the
places and people they study (cf. Cronon, 1991,

1995; Kosek, 2006; Moore, 1998), and the politics of environmental justice (cf. Bullard, 1990;
Heynen, 2003; Pulido, 1996; Sze, 2007). Further, many political ecologists engage with the
material, incorporating understandings of biophysical processes into the questions they investigate 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 ecology 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 relationships and its commitment to mixed methods
that it is well placed to interrogate health and the
body as problems that need to be situated, interrogated with Marxism and feminism, and seen
as more-than-human.4

IV Healthy babies and hungry

babies
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
Becky Mansfield (2008a, 2008b) on the nature
of childbirth in the USA, and place it in conversation with the work of medical anthropologist
Nancy Scheper-Hughes (1993) on childhood

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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. Specifically, Mansfield interrogates her own experiences of giving birth, meditating on what and
who makes childbirth natural. She uses autoethnography along with textual analysis of popular and commonly-available parenting books.
So doing, she finds that childbirth becomes natural through the social relationships around
birth, rather than through a womans 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 (Mansfield, 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 incorporating sociocultural, political-economic, and
material aspects of health through a mixedmethodological 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 spectacular 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, sickness, 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 economy. When Death Without Weeping is put
alongside Mansfields new work, the similarities 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) work on malnutrition with an ethnographic analysis of how people
in Bom Jesus understand and experience nervoso.
She then places this in the context of a wider, global political economy. So doing, she shows how
the population becomes prey to the medicalization of their needs in a resource-poor area where
increases in income and access to food are impossible and hunger becomes medicalized rather
than politicized (Scheper-Hughes, 1993: 169).
In her analysis, Scheper-Hughes has a profound
respect for how those who are suffering from nervoso articulate their illness; a condition she
argues is as much about poverty and disenfranchisement 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 demonstrate a nuanced engagement with questions of

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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 ethnography, adding layer after layer, from an historical 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 methodological 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 to
resort to such fragmented concepts as the biosocial, 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. (ScheperHughes and Lock, 1987: 10, our emphasis)

Scheper-Hughes and Lock suggest that understanding 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 beginning 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 historically produced. Below we offer three perspectives distilled from history of medicine,

science and technology studies (STS), and medical 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 conduct 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 thoughtful 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 Mansfield, 2013) that seeks to understand how some
bodies (and babies) become healthy while others 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; how Marxism and feminism can be used as an analytical framework; and
how the non-human mediates (un)healthy
nature-society relationships.

V Toward a practice of a political

ecology of health
1 Angle one: partial and situated
knowledges
[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, physiological not risky, pathological experience.
(Mansfield, 2008b: 1094)

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I want to show how medicine first begins to capture the imagination of people who, until quite
recently, interpreted their lives and their afflictions and experienced their bodies in radically different 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 biomedicine.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 production 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 attention to scholars who incorporate the role of nonhumans 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 situating, where partiality and not universality is the
condition of being heard to make rational
knowledge claims (Haraway, 1988: 589). For
Haraway, acknowledging partiality and recognizing 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 objectivity 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 investigation and an integral method for a political ecology of health.
STS interrogates the production of scientific
knowledge through an analysis of both the products (or objects) of that knowledge and the processes by which the knowledge is formulated.
To do this, scholars use a mix of methods from
collecting and critically interrogating documents 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 scholars triangulate their sources and use (and produce) 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 experience, cultural interpretations, and broader
political-economic contexts. Similarly, political
ecologists who engage with STS have shown that
there is more to study when it comes to knowledge than production: circulation and application
matter too (Goldman and Turner, 2011). If we are
to take seriously the idea that knowledge is partial and situated, we should also think about what
happens when that knowledge leaves the hands
(and minds) of the people who create it; we ought
to focus on its application.
The history of medicine shows how knowledge 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 conversation with other ways of understanding. In
Colonizing the Body, David Arnold (1993)

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reveals that colonial medicine was central to the

colonial political project, incorporating subaltern
studies and Gramscian ideas about hegemony.
Steven Epsteins Impure Science (1996) investigates 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 knowledge and people, as he follows Kuru/prion scientists 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 triangulation 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 subaltern voices and the daily lives of healthy and
unhealthy people, their investigations of knowledge tend to focus on production and circulation, rather than application.
To map out the global unevenness of knowledge, 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 experience ill health and medicine (Kleinman, 1988).

They also address scarcity within global political 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 anthropologists 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 anthropologists 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 nonbiomedical understandings of what harms and
what heals (Feierman and Janzen, 1992; Livingston, 2005). Through this approach, anthropologists provide rich and detailed accounts of
people and knowledge as situated in particular
times and places.
Together, scholars from STS, history of medicine, and anthropology offer tools for a practice
of a political ecology of health. With attention to
social relationships, place, and time, as understood
through the use of biomedicine, documents, ethnography, 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 situated, and that their circulation and application matter. It is here that the idea of partial and situated
knowledge turns from question to method in political ecologies of health. In order to recognize this
shift, we suggest creating methodologies that

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include knowledges from different subject positions and writing self-consciously about the production of our own work. These lessons remain
at the forefront as we integrate our next two angles.

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 paraphrase 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 influenced 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 ecologies of health, we can ground the practice of
research in a deep engagement with materiality and politics. Further, only when feminism
fully incorporates intersectionality can the interactions 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 politicaleconomic 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 circulations 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 structural 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 global 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 practice 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 intimate relationships. These decisions, as Hunter
reveals, then place their health at the gravest
risk. Likewise, Craddock (2000) reveals that

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class structures are embedded in racialized built

environments that shape how infectious diseases spread, who gets sick, and who determines
policy. In this work, the emphasis on political
economy and class is strengthened through analytics 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 political economy (Gibson-Graham, 1996; McDowell, 1992; Rose, 1993), implemented through
qualitative and self-reflexive methodologies.
To bring together Marxist attention to scarcity, global political economy, and everyday
life with the personal-is-political insights of
feminism, we offer the concept of social reproduction (Mitchell et al., 2004). Following Mansfields 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 simple
event 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 precariousness 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 relations, 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 politics, 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 discussions 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 practices of survival, beyond birth. In this, we hear
echoes of Scheper-Hughess work. Here, the birth
of the worker and the daily (re)production of the
body, as well 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 material, social, cultural, and knowledge-related
aspects of social reproduction.
Following this example, we see a Marxistfeminist approach pushing forward our understanding 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 workers, and to the production of healthy people. By
contrast, unhealthy bodies are constructed as
unproductive, as not yet fully human, as insufficiently socially reproduced. Using a Marxistfeminist approach shows us that sick bodies
are just as fleshy, messy, indeterminate, and

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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 childhood dovetail neatly with some of the core
insights of social reproduction and Marxistfeminist approaches more broadly. Further, this
framework helps us to make sense of the differences and similarities between the two works
Mansfield offers an active political choice of
natural childbirth (highlighting the personal-ispolitical methods of feminist scholarship) and
Scheper-Hughes gives us an account of the limited choices of mothers in poverty-stricken Bom
Jesus (highlighting the importance of Marxist
political economy). In both examples, the question of who is successfully socially reproduced
and how (who is healthy) is as much about
political-economic structures as it is about sociocultural context. A Marxist-feminist approach
allows one to place these different cases in conversation, 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-human

geographies
How do we avoid biological determinism or naive
notions regarding the independence of nature
without falling into the trap of denying the existence 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: brackish, 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 nonhuman agents make people sick (or healthy). In
doing so, we strive to pay attention to the networks 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 (Guthman, 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 conundrum 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 understand 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

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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, provides 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 trypanosomiasis 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 unpredictable 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 medicine, science, history, health, and environment is
the special issue of Osiris, Landscapes of Exposure (Mitman et al., 2004), which opens up questions about health and the non-human. In the
introduction, Mitman et al. offer three key
themes which overlap with the work of geographers: scale, materiality, and uncertainty. Geographers 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 molecular world [and is] understood in terms of a general 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-inthe-making, stressing accumulation and social
reproduction (Harvey and Haraway, 1995:
515). They showed that open and porous bodily accumulations can and do include social and
power relations, toxins, bacteria, food, representations, labor relations, and so on (Harvey,
1998; Harvey and Haraway, 1995). Moving the
discussion further through the frame of environmental 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-innature, 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, materialization, and regimes of perceptibility to show
the porous boundaries between bodies and the
environment. For Murphy, bodies are materialized otherwise, in relation to the myriad
non-human actors around and within them.
Secretaries, air-conditioning, dust-mites, and
carpeting form assemblages located in workplaces where the very idea of being sick is
contested. In this account, personal knowledge
of illness becomes a method for political mobilization. In Murphys book, all three of the

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questions we have worked through come together:

bodies are materialized through their interactions
with non-human actors in a broader politicaleconomic 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 nonhuman into our geographies of health because
understanding health as more-than-human blurs
the boundaries between people and their environments. 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 nonhuman (as well as human) actors. And, as we
have described in detail above, political ecology, medical anthropology, STS, and environmental history all use mixed methodological
approaches that include (the critical use of) science and qualitative data. By triangulating these
perspectives and weaving together these various
scholarly approaches, we offer a distinct practice 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 interrogation 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 reproduction 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 ecology 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 bodies. We believe that the practice we have triangulated 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 generations. To this, we would add that the reproduction 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 the porous boundaries between bodies
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

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of the [geographic methodological] tool kit

(Guthman and Mansfield, 2013: 487). Guthman
and Mansfield, along with other political ecologists, 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 formulating a distinct practice of a political ecology
of health requires us to understand health, the
environment, and the body as neither predetermined 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 Mansfield and Scheper-Hughes have shown, knowledge about health is situated and partial,
structured by class and gender, and shaped by
a more-than-human world. Through their example, 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 political ecology of health through these three
perspectives, we echo the growing call that
health is inherently a nature-society relationship (Mansfield, 2008a: 1015). Yet we recognize that how nature-society relations become
ingrained in the questions and methods of geographies of health remains open. We have proposed 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 chosen, the most striking of which is the question
of health itself, what it means, whom it is for.
How might this practice contribute to novel conceptions of health, both grounded and problematized 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 notfor-profit sectors.

Notes
1. Following convention, the authors are listed alphabetically 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 ecology, see Mollett and Faria (2013).

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