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Progress in Human Geography 29, 4 (2005) pp.

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Medical geography: therapeutic places, spaces and networks


Fiona Smyth
Geography, School of Environment and Development, Manseld Cooper Building, University of Manchester, Manchester M13 9PL, UK

I Introduction Over the course of the last 10 years, the practice of medical geography has undergone a signicant transformation as many have taken on board Kearns (1993) appeal for a reformed medical geography and the encouragement to engage with public health concerns and aspects of social theory through a recentring of place in medical geography research. Indeed, some have argued that since the mid-1990s medical geography has been in the transitional phase of a paradigm shift (Kearns and Gesler, 1998: 1) as it moves out of the shadow of medicine and becomes reinvented as geographies of health and healing (Kearns and Gesler, 1998: 3). Symptomatic of such changes in the discipline has been emergence of a signicant body of research focused on the relationship between place and varied therapeutic processes. Much of this work builds on the conceptual framework outlined in Geslers (1992) paper in which he set out to explore why certain places or situations are perceived to be therapeutic (p. 735) and outlined the potential contribution of developments within cultural geography in addressing such concerns. He argued that the notion of a therapeutic landscape could be seen as a geographical metaphor that would facilitate new ways of
2005 Edward Arnold (Publishers) Ltd

thinking about the relationship between health and place. In particular, Gesler sought to develop a framework within which medical geographers (or geographers of health) could appreciate and, more specically, understand how the healing process works itself out in places (or situations, locales, settings and milieus) (Gesler, 1992: 743). The notion of therapeutic landscapes has been embraced by geographers of health and yielded a signicant, and growing, body of recent research. In this report, I divide this research into three major themes. The rst encompasses the initial work on therapeutic places that explored some of the ways in which specific places developed, and have subsequently sustained, a reputation for healing. The second considers a more recent body of work on more generalized therapeutic spaces including the spaces within which health is played out such as the institutions of health care, including hospitals and clinics, and other institutions that provide therapeutic functions. Within these spaces, the specic geographical location is of less signicance in its therapeutic role than the physical, social and symbolic organization of the space itself. Finally, the third element of this research reects on the notion of therapeutic networks through which people gain support
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Fiona Smyth and care, often outside the biomedical tradition. Therapeutic networks include kinship groups and networks of care provided by family, friends, therapists and other agents of support. The paper considers the contributions of these research themes to date and reflects on possible future directions for inquiry. II Therapeutic places Geslers (1992) paper was committed to developing the concept of therapeutic landscapes in a way that would encourage new ways of thinking about the relationship between health and place by drawing on social theory and more abstracted notions of place. None the less, the rst papers sought to develop the concept by focusing on the literal relationship between health and location by exploring the healing properties associated with particular environments. Indeed, the earliest papers focused on places that have achieved lasting reputations for providing physical, mental, and spiritual healing (Kearns and Gesler, 1998: 8). Research tended to examine the extraordinary places of healing and well-being such as Lourdes, France (Gesler, 1996), Epidauros, Greece (Gesler, 1993), Bath, England (Gesler, 1998), Hot Springs, South Dakota (Geores, 1998) and the Denali National Park in Alaska (Palka, 1999) within which the natural characteristics of the landscape such as the nature, topography and springs were associated with improving and maintaining health (although see Airey, 2003). In most instances, it could be argued that it was the particular geographies of such places that had made them important in historical times. In particular, many healing places were located in areas close to springs and other sources of water, a precious resource for sustaining life and, consequentially, central to many religious and spiritual ceremonies. The significance of water manifests itself differently in various religions but, none the less, in Christianity, Judaism, Islam, Hinduism and other religions, water plays an important role in practices and

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beliefs. Furthermore, particular places are often seen as holding signicance in religious ceremonies. In India, for example, holy places are usually located on the banks of rivers, coasts, seashores and mountains with sites of convergence, between land and rivers, carrying special significance and believed to be especially sacred. The legacy of such religious beliefs is played out in other contexts too where water is important in secular thinking in its links to dirt, disease, cleansing and purity. In the eighteenth and nineteenth centuries, for example, philanthropists expressed concern about the high population densities living in tenements in European and American cities. They feared that such locations were the breeding grounds for dirt, epidemic disease and vice and, thereby, posed a threat to the social order (Curtis and Biran, 2001). Reformers campaigned to establish new laws and institutions that would ameliorate conditions and restore a manner of social order. On the one hand, they sought structural reform through the expansion of government functions to include housing, public health and city planning. On the other, they sought moral reform and campaigned for issues from prohibition to the censorship of films (Guseld, 1997). Water has played different roles in our understandings of health as ideas about disease and medicine have changed over time. As such, it can be seen that the therapeutic qualities of these particular places may become reinvented as a result of changing views about well-being. In many ways, therefore, the therapeutic places described above were more particularly extraordinary because of the enduring nature of their therapeutic label. Similarly, such studies demonstrated the ways in which peoples behaviour and ideas about health are deeply embedded in place and showed how many therapeutic places were commodified and marketed as places of healing and recovery (see, for example, Geores, 1998). As such, researchers demonstrated the dynamic and constructed

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Medical geography the less extraordinary locations of health care including institutional spaces such as the hospital (see Kearns and Barnett, 2000; Kearns et al., 2003; Gesler et al., 2004), the birthing room (Fannin, 2003), the family planning clinic (Gillespie, 2002) and other sites where health care is not the primary function such as the prison (Stoller, 2003), schools (Holt, 2003) and the gym (Andrews et al., 2005). Unlike the therapeutic places described previously, this growing body of literature has tended to examine the spaces within which health is played out. Rather than focusing on natural elements of the landscape and their relationship to health, recent research has tended to examine the constructed spaces of health, often with attention to the ways in which such spaces may be untherapeutic, as much as the ways in which they serve to perform particular therapeutic functions. In this way, geographers have begun to explore the different components of therapeutic landscapes and the ways in which these environments reect different ideological imprints (Kearns et al., 2003: 2304). Attention has been paid to the location, internal design and architecture of therapeutic spaces (physical landscapes), to the people interacting within these settings (social landscapes) as well as to elements of the symbolic landscapes (objects, artifacts and language) within these spaces. The location of institutions of health care has tended to reect the ways that diseases and health are socially constructed. In the nineteenth century, for example, hospitals were designed to incorporate fresh air, adequate daylight and low population densities (Gesler et al., 2004). Similarly, the asylum was often located in a rural location with clean air and free-draining soils (Philo, 1987). In essence, philanthropists of the time sought to bring elements of rurality into the institution and, thereby, address the suspected cause of much illness, namely urban living. Yet, in line with Foucault (1988), it could be argued that within such institutions social reformers also sought to encourage particular

nature of many therapeutic places and raised questions about the ways in which we conceptualize place. As Dyck (1999: 247) argues, geographers need to engage with the recursive constitution of place and people, rather than conceptualizing places and spaces as unchanging backdrops. In the same way, geographers of health need to reflect on changing understandings of disease through time. Like places, diseases (and health) are not xed realities but are situated and socially produced in particular historical, social, economic, cultural and political contexts. The contribution of research into therapeutic places, therefore, has not simply been to identify and develop understandings of particular places and their relationship to health but to demonstrate the complexity of such relationships and to raise questions about the changing conceptions of place, disease and health. III Therapeutic spaces In the arena of public health, there has been recent interest in healthy places (Frumkin, 2003) and in ways of creating healthy communities (Srinivasan et al., 2003). Indeed, Frumkin (2003: 1454) has argued that public health needs to rediscover the importance of place in future research agendas. Yet, despite the vocabulary, the concerns of these public health professionals have been with spaces. Srinivasan et al. (2003: 1446) outline evidence that physical and mental health problems relate to the built environment, including human modified places such as homes, schools, workplaces, parks, industrial areas... while Frumkin (2003) is concerned with the role of buildings, public space, interaction with nature and urban form in creating and sustaining healthy places. While such research may be in its early stages within public health, geographers have much to contribute to such debates. Recent work examining the relationship between health and place has tended to focus less on specic places and, instead, has paid attention to therapeutic spaces. As such geographers have concentrated attention on

Fiona Smyth behaviours that would restore the values they believed to have been lost through the processes of urbanization and industrialization. In the asylum, men were encouraged to engage in agricultural and horticultural labour (Philo, 1987), while women diagnosed with anorexia nervosa were subjected to moral control in institutions that sought to recreate the social structure of bourgeois family, as William Gull (1874: 26), the man who rst named the condition, described: The patients should be fed at regular intervals, and surrounded by persons who would have moral control over them; relations and friends being generally the worst attendants. The physical landscapes of therapeutic spaces today can similarly be seen to reect the values of our societies. Furthermore, the design of a therapeutic space plays an important role in ordering, contextualizing and situating social relations within that space (McDowell, 1996; Gillespie, 2002). For example, Gillespie (2002: 214) demonstrates how the buildings for the provision of contraceptive services in the UK may be seen to represent a metaphor for a backlash against the sexual liberation of the 1960s with the emphasis on family planning and the medical gaze over female reproduction (see also Wainwright, 2003). In an ethnographic study of a city-centre Family Planning Clinic, she demonstrates some of the ways in which the National Health Service facilitates the surveillance of individual sexual lives and reinforces discourses about heterosexuality and able-bodiment as a norm. The internal structures and arrangements, including the physical separation of lay people and professionals and the role of receptionists as gatekeepers serve to include/exclude individuals and to normalize particular kinds of behaviour. In rather different institutional settings, Stoller (2003) reects on access to health care in three womens prisons in the United States, Holt (2003) considers social practices within schools and Andrews et al. (2005) examine the space of the gym. Stoller (2003) argues that the imposition of rules and

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custodial priorities within the institutional space of the prison reflects stereotypical views of prisoners and results in a structural ordering of space that has been naturalized and often serves to exclude women from treatment. Similarly, Holt (2003) suggests that the organization of space and other mundane practices within schools serve to categorize and construct childrens bodies as either disabled or abled, thereby serving to reproduce cultures of inclusion and exclusion. In the same way, Andrews et al. (2005) highlight the ways in which bodybuilding has a set of rules, etiquettes and activities that engender particular behaviours within the location of the gym. In all these cases, the social and architectural organization of these institutional spaces serves to regulate and normalize particular kinds of behaviour. As such, these spaces could be described as moral landscapes within which stereotypes about normalized sexuality, race, gender roles and body image are reinforced through the ordering of space. It could be argued that most of the therapeutic spaces described so far are long established and the moral landscapes created within such settings may reect the values of former societies. A number of recent papers have begun to reect on current developments within the landscape of health care provision. In particular, they have focused on the new institutional spaces of health care that emerged in western capitalist societies during the latter part of the twentieth century reecting the ideologies of neoliberalism. Kearns et al. (2003) and Gesler et al. (2004) have examined the ways in which new programmes of hospital building, currently being funded through the private sector (in Britain, through the Private Finance Initiative), have resulted in new kinds of institutional spaces of health care that reect new sets of power relations (Kearns et al., 2003). In particular, recent initiatives have resulted in hospitals which offer therapeutic functions but which are also spaces of consumption (Brown and Duncan, 2000). Like the (public) Starship

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Medical geography a landscape of exclusion dened by access to private health care and income as well as by more conventional means such as architecture, design and other artifacts of social control such as language (Gesler and Kearns, 2002). In contrast to this marketing strategy, that glamorizes medicine as wondrous and progressive, Fannin (2003) highlights the ways in which birthing rooms in US hospitals have been transformed to downplay technology and, thereby, create home-like spaces of wellness that attempt to conceal the ways in which childbirth, and womens bodies, have become increasingly medicalized in recent years. In some senses, the redesigning of this space within the hospital can be seen to dispute the privileged position given to interventions associated with biomedicine during childbirth because it disrupts and reworks the medical paradigm surrounding normative birth (Fannin, 2003: 531). On the other hand, the symbolic landscape that is revealed is a landscape of power; the technology is immediately accessible within the hospital while the home can be recreated. As such, this is a landscape that reies and reinscribes the hospital birth as natural and the domestic as ideal (Fannin, 2003: 531). In this way, the privileged position of biomedicine is reinforced. Like the emphasis on technology in the marketing of the Ascot Hospital, the availability of interventions demonstrates that through the apparatus of science the doctor can see what the patient cannot or make the invisible visible (see Philo, 2000), thereby reinforcing the cultural assumptions of biomedicine and the practices that sustain its position (see Demeritt, 1998). IV Therapeutic networks Unlike notions of therapeutic spaces, therapeutic networks are less formalized arrangements of support and care that often exist outside (or in parallel to) the traditions of biomedicine. Researchers have explored a wide range of contexts within which care is provided through networks of support

Hospital in Auckland (see: Kearns and Barnett, 1997; 1999; 2000), these hospitals are being designed in response to consumerist pressures which has resulted in a blurring of boundaries between health care/welfare and consumerism (Gesler et al., 2004). Recent hospital design has borrowed from nonclinical settings in its attempt to create therapeutic spaces which have sometimes resulted in hospitals with water features and market stalls that resemble those outlined by Goss (1993) in his account of North American shopping malls. Yet the programme of hospital building Gesler et al. (2004: 126) outline demonstrates the ways in which the designers of the new generation of hospitals have attempted to reconcile many of the traditional functions ... with their consumer-oriented role as providers of accessible health care, advice and treatment although the effectiveness of such new designs is yet to be evaluated. The ideologies of neoliberalism extend beyond the architecture of the building, however, and inuence the discourses of health care and the ways in which services are provided. The pressure to corporatize under the rhetoric of competition has meant that many hospitals have begun to market their products as they compete for customers. In New Zealand, for example, Kearns et al. (2003: 2313) show how language has been deployed to construct the Ascot Hospital as part of the community replete with expertise and technology, and reecting a new age of medicine. They argue that the hospital is marketed as a therapeutic space of comfort and care located within a golden site with spectacular views but that a signicant element of the marketing strategy has been to emphasize the new technology available within this private hospital and, in doing so, emphasizing the hospital as the domain of the medical profession. At the same time, however, it could be argued that such marketing strategies serve to identify the elements of the private hospital that are not available within the public sector and, thereby, emphasize the ways that new technology is creating

Fiona Smyth including, for example, transitory spaces of care for homeless people provided by hostels, day centres and the soup run (Johnsen et al., 2005); the networks of support within communities of First Nations people (Dobbs, 1997, cited in Gesler and Kearns, 2002; Wilson, 2003), the home (Williams, 2002) and care provided by alternative therapists and related service providers (Williams, 1998; Wiles and Rosenberg, 2001; Andrews, 2004). At a time of considerable change in the ways in which health care is provided within western countries, the concept of a network may enable geographers to think about the provision of health care in new ways. Health care is increasingly being provided outside the formal setting of the institution and inside more informal settings such as the home, the garden (see Twiss et al., 2003; Milligan et al., 2004) and the community where multiple sources of support may exist in the form of a therapeutic network (including online support services such as NHS Direct). Such changes impact upon those seeking care and those providing it, adding to the complex relationship between health and place (see, for example, Williams, 2002). In recent years, there has been a signicant growth in the practice of alternative and complementary medicine and therapists are now recognized as signicant providers of health care within Europe and North America (Andrews, 2003). The therapeutic settings of such care range in scale from micro-level (individual clinics, lone therapists and users homes) to the macro-level of towns and regions where a range of therapeutic functions is available (including organic food, vegetarian cafs, new age clothing and bookstores). Williams (1998), Wiles and Rosenberg (2001) and Andrews (2003; 2004) demonstrate that, within the context of complementary medicine, a strong sense of place potentially enhances the healing process (Andrews, 2003: 342). In particular, many users appear to perceive the place of healing as extending beyond the formal spaces of care (clinics) into the community

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and home, thereby, creating a therapeutic environment. In a similar way, research on therapeutic practices outside the tradition of western biomedicine emphasize the ways in which well-being is seen to be a product of a combination of different elements within the landscape (Williams, 1998; Wilson, 2003; Del Casino, 2004). Wilson (2003: 84), for example, argues that health geographers have failed to acknowledge the ethnic and racialized underpinnings of the relationship between health and place and that, for First Nations peoples, health is constructed as involving both physical (absence of disease) and symbolic (balance between the individual, society and spiritual realm) healing. Such holistic notions of health suggest that well-being is more than the absence of disease and, similarly, healing is an extensive concept that involves more than a simple cure. Yet such notions of health and its connection to place may romanticize the relationship between the landscape and well-being through claims of authenticity and inclusion in a way that privileges alternative therapies as systems of healing and fails to recognize that, like other therapeutic landscapes, these networks may be exclusionary as well as inclusionary. None the less, it is clear that the boundaries between nonwestern and western medicines and between biomedical and alternative therapies are becoming increasingly blurred. On the one hand, health care is beginning to be more broadly conceived with traditional medicines being made available alongside biomedical alternatives (see, for example, Quah, 2003; Del Casino, 2004). At the same time, alternative and complementary therapies are being increasingly regulated and professionalized, thereby establishing new discourses and potentially constructing new landscapes of exclusion (see Bondi, 2004; Clarke et al., 2004). V Conclusions The physical, social and symbolic landscapes of therapeutic environments (including places, spaces and networks) serve to regulate and

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normalize certain kinds of behaviour and to include as well as exclude. As such, these spaces can be seen as texts upon which ideologies and discourses become inscribed in ways that uphold power and social divisions (Gillespie, 2002: 219). Yet, in recognizing the ways in which such environments regulate behaviour, we can expose the ideological foundations upon which our understandings of disease and health-related behaviour are based. In doing so, we can begin to expose a space for passivity to give way to new opportunities to develop landscapes of resistance and activity that challenge exclusionary discourses about ethnicity, race, impairment and gender and discourses about particular conditions such as psychiatric disorders, HIV/AIDS and other sexually transmitted infections. Similarly, as the spaces of health care become increasingly blurred, new opportunities arise for us to explore new spaces of health care that may help us to understand better the relationship between health and place that can then be used in positive ways to develop therapeutic places that actively promote health and well being (Milligan et al., 2004: 1790). Acknowledgements Many thanks to Neil Coe, Peter Dicken and Ron Johnston for their support and comments during the preparation of this paper. References
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