Global Health: Geographical Connections

By Anthony C. Gatrell

Drawing on the latest research in health geography and a wide range of case studies from across the world, this comprehensive and authoritative study offers students an unrivalled analysis of the geographical connections of global health and the challenges they present for governance and treatment. Topics considered include health inequalities across countries, the governance of health by nation-states and international organizations, the incidence and spread of infectious disease, the links between air and water quality and health outcomes, and the health impacts of climate change. The book considers how these different issues play out in a range of geographical settings across the world, with a particular focus on low- and middle-income countries, which are disproportionally affected. The book demonstrates the indispensable role of geographical processes operating across borders in understanding health worldwide and is an excellent resource for courses on health geography, global health, public health and development studies.

• Language: English
• Publisher: Agenda Publishing
• Release date: Sep 7, 2023
• ISBN: 9781788215022

Anthony C. Gatrell

Anthony C. Gatrell is Emeritus Professor of the Geography of Health at Lancaster University. His books include Geographies of Health (with Susan Elliott) (Third edition 2015). In 2006 he was awarded the RGS-IBG Murchison Prize for his contribution to the geography of health.

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Global Health

Agenda Human Geographies

The Agenda Human Geographies series explores contemporary issues, debates and controversies from geographical perspectives and presents the distinctive contributions offered by the discipline. It examines a wide range of topics such as health, globalization, development, justice, migration, race, gender and sexuality, inequality, culture and crime. New and emerging areas as well as established fields come under the spotlight in thought-provoking and incisive discussions by leading scholars. Books are written for an international readership studying, researching and engaging with geographical thought. They are suitable for upper-level undergraduate and postgraduate course use as well as scholars working in geography and related disciplines.

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Global Health: Geographical Connections

Anthony C. Gatrell

GLOBAL HEALTH

Geographical Connections

Anthony C. Gatrell

© Anthony C. Gatrell 2023

This book is copyright under the Berne Convention.

No reproduction without permission.

All rights reserved.

First published in 2023 by Agenda Publishing

Agenda Publishing Limited

PO Box 185

Newcastle upon Tyne

NE20 2DH

www.agendapub.com

ISBN 978-1-78821-499-5 (hardcover)

ISBN 978-1-78821-500-8 (paperback)

British Library Cataloguing-in-Publication Data

A catalogue record for this book is available from the British Library

Typeset by Newgen Publishing UK

Printed and bound in the UK by CPI Group (UK) Ltd, Croydon, CR0 4YY

Contents

Preface

List of figures, tables and boxes

1Introduction

2Unequal health I: determinants and regional examples

3Unequal health II: key themes

4Governing global health

5People on the move: the dispossessed and their health and wellbeing

6Materials on the move: out of the ground, and across the globe

7Airs, waters and places

8Infections on the move

9Climate change and global health

10Conclusions: global health and cross-cutting themes

References

Index

Preface

Although I am a geographer who has been interested in health issues for 40 years, my research has been almost exclusively focused on countries in the Global North, and even more exclusively on the United Kingdom. More specifically, it has embraced geographical epidemiology – the study of disease and illness in particular places – involving a mix of (usually) quantitative and (sometimes) qualitative methods.

The discipline of health geography, which Susan Elliott and I have sought to summarize in three editions of Geographies of Health (2015), has undergone various shifts in emphasis over the last 30 years or so. I have been led to write this present book in part because of the relative lack of research by geographers on global health. Much of the recent focus in health geography has been on topics that have (for example) explored the health and wellbeing of those living near green spaces and attractive walking environments. Yet, in many parts of the world, walking is less for pleasure and more for access to clean water or escape from violence. I hope here to have addressed key issues that affect those living and working outside Anglo-America and Europe; for sure, I have cast my net wide and have endeavoured to cite literature written by those living and working in regions other than my own.

The subject of global health demands an interdisciplinary perspective. The late Paul Farmer and his colleagues have cited anthropology, sociology, political economy and history as the key disciplines (Farmer et al. 2013). In this book I am adding geography to the mix, recognizing of course that it too draws theory and concepts from those and other disciplines. As Herrick and Reubi suggest in the introduction to their edited collection (2017b: x), Geography has not yet carved out a disciplinary niche within the diffuse domain that constitutes global health. I wish to help the inscription, which remains insufficiently carved: more than ten years have passed since Brown and Moon’s (2012) important commentary on geography and global health, although the brief chapter by Brown and Taylor (2018) in Crooks, Andrews and Pearce’s comprehensive Handbook of Health Geography offers a tantalizing taste of a research agenda and other chapters in that collection discuss global health concerns. So too does a chapter on global health geographies in the excellent co-authored text by Brown and colleagues (2018). Clare Herrick is doing much to bring geographers to the table, as my references to her work make clear. However, scrutiny of recent issues of the subdiscipline’s leading journal, Health & Place, suggests that, despite a growing number of papers, the topic has yet to really fire the imagination of the current generation of health geographers.

It seems to be the case, certainly in the Covid-19 era and for lay audiences, that global health for some means largely a focus on pandemics. I want to show that it embraces so much more than this. There is a wealth of literature on the various topics I cover, drawn (as the references make clear) from a wide variety of disciplines and by authors from the Global South as well as the North. I have always enjoyed ranging across disciplinary boundaries, and I hope the book may therefore appeal to those working outside my home discipline of geography. My debt to medical anthropologists in particular will become clear to readers.

This book is subtitled Geographical Connections. This indicates that I wish not only to draw out the ways in which geographers can contribute to, or connect with, the global health agenda but also, more importantly, to suggest that we live in a connected world in which what matters is the sets of relations between elements or entities, whether human or material, social or organizational – or, indeed, all of these. Global health means focusing on issues that impact on particular countries but, crucially, span international borders. As geographers looking at global health, we are concerned with describing and explaining place-to-place variation and connectivities in health (and disease), for which the explanations are multifaceted and demand an engagement with politics, economics and environmental science. But it also means a concern with inequality. At the same time, it is important not to overplay a litany of health problems, illness and disease. Although the contents suggest that the book might well have been titled Global Disease, it is clear that people and communities can resist being labelled (even stigmatized) as universal victims of political and economic forces beyond their control.

Aside from those on whose research I have drawn, many others have helped me, particularly those showing personal interest and support in the project. I am especially grateful to Camilla Erskine at Agenda Publishing for her keen interest in the project and her encouragement throughout. I also thank Mike Richardson for his very careful copy-editing of the manuscript. Two reviewers, both of the original proposal and the submitted manuscript, made very helpful and detailed comments, which I have sought to incorporate. I thank them sincerely.

The references section indicates where many of my intellectual debts are owed, but the interest in this project shown by friends and family has meant a great deal. My twin brother Peter commented on the proposal, and anyone interested in refugee history will be familiar with his work, notably his The Unsettling of Europe (2019). My wife Caroline, and daughters Anna and Emma, have followed its progress keenly and have also offered considerable support. Their love and inspiration – as scholars themselves – has, for a writer on global health, meant the world.

Tony Gatrell

Lancaster

List of figures, tables and boxes

Figures

1.1Haiti as a living laboratory for the study of affliction

1.2The Brandt line separating the Global North (developed) from the Global South (developing)

1.3Musgamagw Tsawataineuk protests at a salmon fish farm

1.4Space–time convergence

2.1Institutional birth delivery coverage according to wealth quintiles and place of residence in selected countries

2.2Brazil: regions and states

2.3Poverty, illiteracy and life expectancy in Brazil

2.4India: states and territories

2.5China: provinces

2.6Life expectancy at birth in China, 2010

2.7Provinces of Mozambique

2.8Provinces of the Democratic Republic of the Congo

3.1Poster of Indian actor Jackie Shroff promoting cigarettes

3.2Dharavi slum in Mumbai, India

3.3Contrasting places: the Paraisópolis favela and luxury buildings in São Paulo, Brazil

3.4Age-standardized disability-adjusted life years resulting from depression

3.5Palestinian children in the Gaza Strip

3.6Association between sustainable development and subjective wellbeing

3.7Association between child mortality and provision of physicians, 2002

4.1World Health Organization HQ, Geneva, Switzerland

4.2GAVI: Global Alliance for Vaccines

5.1Number of internally displaced persons, December 2020

5.2Mapping deaths of people trying to cross the English Channel, 2019–21

5.3Balukhali Rohingya refugee camp in Ukhia, Cox’s Bazar, Bangladesh, February 2019

5.4The Calais jungle, October 2016

6.1Extracting e-waste at the Agbogbloshie scrap market, Accra, Ghana

6.2Living in Yemen: the devastation of war

7.1Aerial view of the industrial gas leakage site situated at Bhopal, Madhya Pradesh, India

7.2Death rates from outdoor air pollution, 2017

7.3The Mekong river basin

7.4Women collecting water near Mzuzu, Malawi

7.5Water and food insecurity intersect to cause health problems

7.6A tubewell in Bangladesh where water is contaminated with arsenic

8.1Stagnant water as breeding ground for Aedes mosquitoes

8.2Spatial variation in malaria linked to two parasite species in Brazil, 2018

8.3Ebola virus disease cumulative incidence, 20 September 2014

8.4Caged birds for sale in a wet market in Shanghai, China

8.5Location of patients with confirmed Covid-19 in China, 19 February 2020

8.6Global inequality in number of Covid-19 vaccine doses administered by April 2021

9.1Relative risk of heat-related mortality per 10°C increase above the 95th percentile observed daily temperature

9.2Possible shift of infections transmitted by Aedes aegypti mosquitoes from 2020 to 2050 to 2080

9.3Pathways of climate change, food security and maternal/infant health reported by mothers in rural Uganda

9.4Conceptual model of climate, conflict and migration

Tables

2.1Sustainable Development Goals

2.2Life expectancy in selected sub-Saharan countries, 2019

2.3Health and social indicators in Brazilian regions, 2013

2.4States in India with health indicators

2.5Child mortality by province in Mozambique, 2003

3.1Percentage of male adults smoking, from SDG Target 3.a, 2007 & 2018

3.2Total alcohol consumption by persons over 15 years (in litres, per capita), from SDG Target 3.5, 2000 & 2018

3.3Age-standardized years of life lost per 100,000 in China, 2017

3.4Age-adjusted percentages of Native American adults in fair or poor health, by area type, 2014–18

3.5Disability scores in contrasting census areas in Rio de Janeiro, 2006

5.1Global forced displacement, 2020

6.1Blood lead levels (in µ/dL) in a town handling e-waste (Giuyu) and a comparison town (Chendian), China

8.1The major neglected tropical diseases

8.2Estimated excess mortality rate (per 100,000), and reported Covid-19 deaths, by country/state, 2020/21

8.3Countries with fewer than 5 per cent of the population fully vaccinated, April 2022

10.1Cross-cutting themes in health geography and global health

Boxes

1.1Structural violence

1.2What’s in a name?

1.3The political ecology of health among ’Namgis First Nations in British Columbia

1.4Assemblages and the post-human turn in health geography

1.5Universal truths and situated knowledge

2.1Political and commercial determinants of health

2.2The Uighur population in Xinjiang province

3.1New markets for smokers

3.2The Gender Inequality Index

3.3Historical trauma

3.4Antidepressants in the Global South

3.5Child mental health in Gaza

3.6The inverse care law applies in the Global South too

4.1The Alma Ata conference (1978)

4.2The Washington Consensus

4.3Getting TRIPed up

4.4The 2014 Ebola outbreak and the role of MSF

4.5The Bill & Melinda Gates Foundation (BMGF)

4.6Global health surveillance

4.7The Global Health Security Index

5.1The Internal Displacement Index

5.2Fleeing Sudan

5.3Attempting to cross the English Channel

5.4Rohingya refugees in Bangladesh

5.5One woman’s search for safety: Zarlasht Halaimzai

5.6Ontological security and the emotional health of refugees

5.7Every child protected?

6.1Global Environmental Justice

6.2Pollution havens

6.3From structural violence to slow violence

7.1A story from Bhopal

7.2Transboundary issues in the Mekong river basin

8.1A syndemic perspective

8.2Zika virus

8.3Antimicrobial resistance

9.1The coloniality of climate change

9.2Climate change, population displacement and political conflict: a cautionary tale

9.3Adapting to climate change: a critical perspective

10.1A happy planet?

10.2Health and human rights

1

Introduction

Clearly, many disciplines, such as the social and behavioural sciences, law, economics, history, engineering, biomedical and environmental sciences, and public policy, can make great contributions to global health.

Koplan et al. (2009: 1994)

Geographies of health

Human geography is the study of human activity in relation to the places and environments that people inhabit, and health geography seeks to describe and explain how health (and wellbeing, and illness and disease, and the determinants of such) varies from place to place (Gatrell & Elliott 2015; Brown et al. 2018). Places can encompass diverse settings, including the home, workplace, neighbourhood, region and country. As a result, the subject matter spans a considerable range, such as the experiences of those living at home with chronic illness, how access to resources affects the wellbeing of those living in different neighbourhoods, and regional inequalities in morbidity and mortality. Most importantly, as I hope to show in this book, relations between (and within) different nation states; the flows of people, materials and infections, along with the historical, political and economic linkages between them, are – or should be – a focus of health geographers’ attention. Geography, as a distinct discipline, should be added to Koplan et al.’s disciplinary mix.

Approaches to the study of health geography are diverse, as revealed in Gatrell and Elliott (2015: ch. 2), the breadth of essays in the collection edited by Crooks, Andrews and Pearce (2018) and the critical introduction to the subject by Brown et al. (2018). Until the 1990s geographical enquiry that focused on illness and disease was labelled medical geography (Mayer 2010 has an excellent overview). Although some of that research looked at the distribution of morbidity (illness) and mortality in advanced economies, other research dealt with tropical diseases such as malaria. That tradition was called disease ecology (Learmonth 1988) – discussed more fully below – and it explored the ways in which the incidence of disease was associated with environmental conditions. Paralleling this was a rich tradition of mapping and analysing the distribution of mortality and morbidity (as well as the spread or diffusion of disease) that led to sophisticated visualizations and spatial analysis, often linked to the use of geographical information systems.

It took a seminal paper by Robin Kearns (1993) to suggest that more attention needed to be given to health, as opposed to disease. Out of this grew a new body of work, more concerned with health in specific social and cultural settings and less with the mapping and analysis of spatial variation in disease. As a result, some health geographers seek to understand how individuals experience (ill) health in different places, drawing on qualitative methods such as interviews, diaries and focus groups. For example, Milligan (2018: 230) considers research on the home a space imbued with multiple meanings linked to identity, safety and security, power and control, emotion, nurture and historical memory. However, such research has tended to relate to homes in the Global North rather than to the safety and security in the dwelling places of those living in countries of the Global South.

A further broad approach to health geography situates health in the wider context of social and economic conditions – a structuralist or political economy perspective. This can draw on a variety of methods, both quantitative and qualitative, but it frequently demands listening carefully to the voices of those usually drowned out by the views of experts and policy-makers. The experiences, beliefs and rights of those living under the constraints of health policies imposed on them provide a body of knowledge that deserves attention. For Bambra, Smith and Pearce (2019: 38), political economy means that population health is shaped by the social, political and economic structures and relations that may be, and often are, outside the control of the individuals they affect. They note that such insights have yet to be fully developed and applied within the literature on health and place.

Although not the exclusive preserve of anthropology, it is that discipline that has majored in a political economy of health and done most to illuminate global health from the perspective of ordinary people. Excellent examples include the rich ethnographic research undertaken on people living with HIV in Haiti (Farmer 2005) and Ebola in west Africa (Farmer 2020). Chapters in the collection edited by Biehl and Petryna (2013) also illustrate the importance of ethnography in revealing the voices and stories of people living, for example, with malaria and AIDS. Biehl and Petryna (2013: 3) argue that looking closely at life stories and at the ups and downs of individuals and communities as they grapple with inequality, struggle to access technology, and confront novel state-market formations, we begin to apprehend larger systems. As this (and Farmer’s work) suggests, ethnographic approaches are essential in a political economic approach. A key concept in Farmer’s work is that of structural violence (Box 1.1).

BOX 1.1 STRUCTURAL VIOLENCE

By structural violence is meant not physical violence (although, as we see later, that is real enough for many in the Global South) but the violence perpetrated by power relations that dictate who lacks access to the basic resources necessary to sustain life. Suffering is structured by economic and political forces (racism, sexism, political instability and macroeconomic policies) to shape and constrain human agency and health. The axes of gender, race and poverty intersect to dictate the health of individuals in specific geographical settings.

One of Farmer’s several books, Pathologies of Power (2005), illuminates in particular the suffering endured by the poor living in Haiti, a country he describes graphically as a sort of living laboratory for the study of affliction (2005: 30): see Figure 1.1. As he notes, we are moved by the suffering of those close to us (think of the impact on health and livelihoods of those affected by severe flooding in mainland Europe, or the displacement of people from Ukraine, or those deeply affected by the hurricanes making landfall in Louisiana, for example) but less moved by the suffering of those who are remote, whether in geographical or cultural terms. To explain such suffering, Farmer exhorts us to connect individual biographies with political economy.

Figure 1.1 Haiti as a living laboratory for the study of affliction

Source: iStock.

Büyüm et al. (2020) write that the Covid-19 pandemic (see Chapter 8) has highlighted clearly how structural violence operates both within and between countries. Structural violence gives precedence to some social groups while disadvantaging and harming others. Herrick (2017a) has drawn on the concept of structural violence in her study of alcohol consumption in South Africa. She sees alcohol consumption in poor urban communities as a form of coping with the structural violence caused by racial segregation, inequality and unemployment.

For a detailed examination, and critique, of structural violence, see Herrick and Bell (2022).

The recent textbook on health geography (Brown et al. 2018) is subtitled A Critical Introduction. By this, the authors mean a key concern with issues of social justice and power relationships. Crucially, and suggesting sympathy with a political economy perspective on the subject, they suggest that a critical approach means paying close attention to those who are marginalized, whether in the Global North or Global South (Box 1.2).

As I have indicated, there has been a discernible shift away from medical geography towards health geography – or, more accurately, geographies, as the titles of two textbooks suggest (Gatrell & Elliott 2015; Brown et al. 2018). But, to date, there has been a relative neglect in that subdiscipline of the bigger picture of global health. This is evidenced by scanning the literature on key current topics. For example, literature on therapeutic landscapes, geographies of ageing and of children, mental health, home environments, walkability, green/blue spaces, and rural health – all considered in a recent edited volume (Crooks, Andrews & Pearce 2018) – have relatively little to say about such issues as they pertain to the Global South. The same may be said about the current interest in wellbeing. As Severson and Collins (2018: 128) put it, Implicit in [that] research is a recognition that well-being – in terms of overall contentment and quality-of-life beyond satisfaction of basic material needs – is something the relatively privileged can afford to work on.

Despite the move away from medical to health geographies, a focus on disease (particularly infectious disease) rather than health has always been a concern of some geographers. Good examples are the body of work undertaken in Britain by Cliff, Haggett and Smallman-Raynor (see, for example, Cliff et al. 2009) and ongoing work by those who focus their attention on disease ecology.

Disease ecology suggests that, to understand the geographical distribution of a disease, we need to link together habitat, population and human behaviour. Habitat includes both the physical, biological and built environments. In a riposte to Kearns’ seminal paper (1993) referred to above, Mayer and Meade (1994: 103) say that disease ecology considers the numerous social, economic, behavioural, cultural, environmental, biological factors which create disease in specific places at specific times. All-embracing as this seems to be, in a later paper Mayer (1996) stresses the political dimension and introduces the political ecology of disease as one new focus (as his title puts it) for medical geography.

BOX 1.2 WHAT’s IN A NAME?

Throughout this book I use Global North and Global South as simple categories, but, as Khan and colleagues (2022) have noted, there is a wide variety of terms – often rooted in colonial thinking (First World and Third World, for example) – that have been used to classify major regions.

The distinction between Global North and Global South has its origins in the Brandt Report of 1980 (Figure 1.2), but, given the complex ways in which globalizing capitalism is reterritorializing human development, poverty, and inequality today, the Brandt Line is becoming less and less fruitful as a heuristic (Boyle 2021: 195). Boyle (2021) goes on to suggest (197) that the First World can now be found in the Third and the Third World in the First. Some areas and communities in the Global North reveal patterns of inequity and ill health that are not so different from those in the Global South.

Figure 1.2 The Brandt line, separating the Global North (developed) from the Global South (developing)

Source: Courtesy of Mark Boyle, Maynooth University, Ireland.

Lencucha and Neupane (2022) argue that classifications such as low- and middle-income countries (LMICs) risk perpetuating hierarchies, constructing one group as subservient to another that extracts wealth and resources from it. Acknowledging the dangers of simple classifications, I use the terms Global North and Global South (and, given their widespread use in the research literature, low- and middle-income countries) as convenient labels, but focus attention on people and places that are peripheral in terms of their relative location in social, economic and political spaces.

Political ecology and health

In understanding the geography of disease and ill health, political ecology conjoins political economy with classical disease ecology, to reveal how economic and political processes and structures interact with environmental processes and constraints to produce ill health. All these processes, structures, determinants and distributions (of ill health) are played out unequally in different parts of the globe. Mayer (1996) gives an example of a political ecology approach, referring to classic research on malaria in the first half of the twentieth century in British Malaya, where large-scale clearance of the jungle had enabled large corporations to build rubber plantations. The removal of forest cover, associated with stagnant pools of water, allowed Anopheles mosquitoes (those carrying the parasite that causes the disease) to breed, exposing workers to disease risk.

In a seminal paper, Chantelle Richmond and her colleagues (2005) adopt a political ecology framework to understand aquaculture in British Columbia, and, as this links a number of themes in the present chapter and the next, it is worth considering more fully (Box 1.3).

BOX 1.3 THE POLITICAL ECOLOGY OF HEALTH AMONG ’NAMGIS FIRST NATIONS IN BRITISH COLUMBIA

Aquaculture – the cultivation and harvesting of fish – is an important contributor to the economy of Canada; about 7 per cent of farmed salmon worldwide is provided from the country, making it the fourth largest producer across the globe. Richmond and her colleagues (2005) note that the industry, centred in parts of coastal British Columbia, has become globalized, with resulting impacts on First Nation communities (specifically, ’Namgis First Nation), for which fishing has been a way of life for hundreds of years. For these communities, and other Indigenous groups, health and wellbeing are embedded in the local environments they inhabit. The threats of commercialized fishing include both environmental and health risks, and Richmond’s research seeks to understand the communities’ own perceptions of these risks. The legacy of colonialism in Canada (British Columbia) means that First Nations’ claims to environmental resources have long been dismissed.

Detailed qualitative research uncovered links between resource use, economic opportunities, lack of autonomy and health outcomes. As one respondent, Robbie, says:

There are always concerns about the health of our people and I think the health of the environment goes a big way towards the health of our people too. I think if your forests and the oceans die, I think the people are going to die along with it. There have got to be measures and steps taken to ensure that we have a healthy land and healthy people.

Marianne comments: We are finding out more about effects from the chemicals to make [salmon] flesh pink … They might have side effects on humans … the antibiotics they are given, might have side effects on humans (quotes from Richmond et al. 2005).

The political ecology framework adopted in this research helps to link the local environmental context, and population health, to broader national and international structures. As the authors’ research demonstrates (Richmond et al. 2005: 352), The theoretical constructs and methodological framework of ‘third world ’ political ecology are equally applicable to peripheral regions within advanced capitalist economies, for instance marginalized populations of the First World such as First Nations communities. Their research brings to the fore how political economy connects with environmental extraction to lay bare the health inequities faced by an Indigenous population (Figure 1.3). Such inequities are considered in detail in Chapter 2 and elsewhere in the book.

Figure 1.3 Musgamagw Tsawataineuk protests at a salmon fish farm

Source: Kwakwaka’wakw: www.firstnations.de/fisheries/kwakwakawakw.htm (courtesy of Karen Wonders, University of Göttingen, Germany).

See Richmond et al. (2005) and Richmond and Big-Canoe (2018) for additional detail.

What happens in particular places cannot be divorced from the wider economic and political context; all scales are mutually enmeshed (Mayer 1996: 447). Presciently (prior to Covid-19), Mayer’s important review discusses the value of a political ecology approach for understanding emerging and re-emerging infections – a theme to which I return in detail in Chapter 8. For example, the emergence of Lyme disease in the United States has been widely linked to the encroachment of suburban housing on previously forested areas, bringing people into contact with animals harbouring the ticks that carry the infectious agent. Mayer also reminds us of the health consequences of constructing the Aswan Dam, a project that was part of Egypt’s drive to post-war industrialization, whereby the accompanying lake behind the dam provided a breeding ground for the snails transmitting schistosomiasis to local populations (see Lerer and Scudder 1999 for a thorough review of the health impacts of large dams, and further discussion in Chapter 7).

Mayer has been criticized for seeming to give more attention to disease ecology than to political economy. As Jackson and Neely (2015: 50) put it: 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. The authors make explicit the links to Marxism and feminism, in which inequalities of capital and gender come into play, revealing how uneven global political and economic processes manifest themselves among those in specific local social and cultural contexts.

Nichols and Del Casino (2021) develop these ideas further, asking what the role is that affect and emotion play in political ecology. They reflect the introduction into health geography of poststructuralist approaches, such as non-representational theory (NRT: Andrews 2018). Here, "affect and energy both provide connective imaginations that indicate how different elements, objects, bodies and surfaces might be brought into inter-relation toward the constitution of health or