Article

Progress in Human Geography 35(2) 153171 The Author(s) 2010 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0309132510376258 phg.sagepub.com

Citizenship, care and companionship: Approaching geographies of health and bioscience

Beth Greenhough
Queen Mary University of London, UK

Abstract Despite a shared interest in engaging critically with biomedicine, there has been little crossover between geographies of bioscience and geographies of health. This paper aims to bridge that gap, using the concept of ontological politics to provide a framework for making connections between geographies of bioscience and geographies of health. Ontological politics can be defined as the conviction that the material or real world does not precede our interactions with it and is therefore open to political negotiation. Within social studies of health and bioscience there is a growing body of work that uses ontological politics to gain insight into relations between biomedicine and society and how these are materialized at different sites and scales, ranging from public health interventions to everyday experiences of patient care. This paper takes three of these sites spaces of biological citizenship, spaces of care, and spaces of cross-species companionship and explores how they might form shared areas of interest for current research in geographies of health and the biosciences. The paper concludes that ontological politics offers a useful starting point from which to develop research agendas which cross the divide between geographies of health and geographies of bioscience. Keywords biological citizenship, care, companion species, geographies of bioscience, health geography, ontological politics

I Introduction
Over the past 15 years geographers have examined how bioscience is refashioning nature-society relations (Braun and Castree, 1998; Bridge et al., 2003; Greenhough and Roe, 2006; Spencer and Whatmore, 2001; Whatmore, 1999, 2002). Adopting a political economy perspective, geographers have emphasized the role of biomedical technologies in facilitating the production of new kinds of bodily commodities (Parry, 2008) and the recognition of new kinds of biosecurity threat (Braun, 2007). This work shows how scientific practice

is changing our relationships with the material world, including the most intimate materiality of human bodies (Greenhough and Roe, 2006). As humans, we see our corporeal substance being extracted and repackaged for the purposes of medical research, treatment and trade (Cohen, 2005; Davies, 2006; Greenhough, 2006; Parry, 2008; Scheper-Hughes, 2000). We are learning

Corresponding author: School of Geography, Queen Mary University of London, Mile End Road, London E1 4NS, UK Email: b.j.greenhough@qmul.ac.uk 153

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to see our biological heritage, and ourselves, in biotechnologically informed ways (Epstein, 1996; Nash, 2005), while simultaneously becoming subject to new forms of surveillance, governance, and control (Parry, 2009; Rose, 2007). The costs and benefits of bioscience are also unevenly distributed (Kearns and Reid-Henry, 2009). By examining the social, political and economic contexts within which bioscientific knowledge is produced and consumed, geographers are also beginning to question the power and authority of western biomedicine and pharmaceutical industries (Craddock, 2008). Alongside this attention to bodily biotechnologies there has been a rise in post-positivist approaches to medical geography. As Parr (2002a) notes, this work has led a shift away from the medical model and towards understanding how health is constituted through the social and cultural environment (Kearns and Moon, 2002), exemplified by the emergence of the journal Health and Place. Health geographers have studied the therapeutic landscapes within which health is experienced (Kearns and Gesler, 1998) and the ways in which place is experienced differently by those with disabilities (Dyck, 1999; Hall, 1999) or chronic illness (Dyck, 1995; Moss, 1999). Much of this work has turned away from biomedical understandings of health and disease, but there is also a growing body of work that engages critically with the spaces of biomedical practice (Parr, 2002a). This new medical geography ranges from examining the role of the state and the market in restructuring healthcare provision in the Global North (Milligan, 1999) and limiting access to essential healthcare resources in the Global South (Craddock, 2008), to studies of how (un)healthy bodies are both socially constructed and materially experienced or lived (Butler and Parr, 1999; Craddock and Brown, 2010; Hall, 2000; Longhurst, 2001; Moss and Dyck, 2002; Parr and Philo, 1995). These two fields of inquiry geographies of bioscience and geographies of health draw
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on largely different theoretical and empirical legacies,1 but share a critical stance towards the dominant western biomedical approach to health and disease. Despite this shared interest there has been little crossover between geographies of bioscience and geographies of health.2 This paper aims to identify a collective research agenda for geographies of health and the biosciences. In building this agenda, I draw the concept of ontological politics:
Ontological politics is a composite term. It talks of ontology which in standard philosophical parlance defines what belong to the real, the conditions of possibility we live with. If the term ontology is combined with that of politics then this suggests that the conditions of possibility are not given. That reality does not precede the mundane practices in which we interact with it, but is rather shaped within these practices. (Mol, 1999: 7475)

The term ontological politics has its origins in the social study of science and technology and in particular actor-network theory (ANT; Law and Hassard, 1999). ANT was used to illustrate how the production of scientific knowledge was a contingent processes. Rather than uncovering universal facts about a pre-existing and fixed natural order, the production of scientific knowledge is dependent on the labour of scientific experimentation, academic consensus and an underlying network of agents and materials. The term ontological politics also captures the political possibilities of recognizing that the material world does not precede the bodies, practices and engagements through which we interact with it. If existing knowledges and understandings are not universal facts, but negotiated and contingent achievements, then they are open to contestation, challenge and reinterpretation. This paper argues that geographies of health and bioscience might also share a commitment to engaging with ontological politics. Within health geography ontological politics provides one route towards resisting the ontological tricks (Philo, 1997) which have shaped health

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geographies in the past. Philo uses the term ontological tricks to describe the passage between thoughts and things: how knowledge of disease mental ill-health for example is transposed into the bodies of individuals who are labelled as mad and onto the material landscape in the form of institutions such as asylums. If we understand such ontological tricks as practices and processes, rather than pre-given truths, then we hold open the possibility for intervening in this passage between thoughts and things, between dominant biomedical modes of understanding health and the practices and processes which they inform. Within geographies of bioscience the concept of ontological politics highlights the political work done by biological and quasi-biological entities in redefining the relationships between science, nature and society. For example, the ways in which bio-information (including biological samples and medical records) has become a commodity within the life science industries (Greenhough, 2006; Parry, 2004). Focusing on these new material entities provides a starting point for tracing the political and economic networks and the state-market alliances required to produce these bio-informatic and pharmaceutical resources (see, for example, Craddock, 2007; Greenhough, 2006). A focus on the ontological, in other words, gives us new insights into the political. Ontological politics therefore offers an approach to geographies of health and the biosciences which could be sensitive to how health and disease are socially and materially constructed and the role of scientific knowledge, and in particular biomedical interventions, in shaping that process.3 A focus on ontological politics also offers an additional advantage; it highlights how work in geographies of health and bioscience both complements and extends work outside the discipline. In this paper, three versions of ontological politics from outside the geography discipline biological citizenship, the logic of care and interspecies companionship provide

a framework for the three substantive sections that follow. Each section explores the operation of ontological politics across different geographical sites and scales, linking this to ongoing work in geographies of health and bioscience. This framework allows for the identification of novel sites of connection between geographies of health and geographies of bioscience, and at the same time builds connections between work in geography and work in medical sociology, medical anthropology and biophilosophy. First, the concept of biological citizenship (Petryna, 2004; Rose, 2007) is used to explore how biomedicine intervenes at a geopolitical4 scale, generating new possibilities for both state regulation and political protest and resistance. Second, I explore how ontological politics is embedded within more localized spaces of care, contrasting the conceptualization of care in health geography with Mols (2008) logic of care. Third, I draw on Haraways (2008) ideas of interspecies companionship to suggest a new site where geographers might begin to explore the intersection of biomedical and health geographies. In concluding, I will draw on these three sites to support my claim that a focus on ontological politics might form a basis for a new research agenda in geographies of health and biomedicine.

II Biological citizenship
Adriana Petryna describes a new kind of social movement that emerged in the Ukraine following the collapse of the Soviet system and the 1986 Chernobyl nuclear disaster. This population named poterpili (sufferers), numbered 3.5 million and constituted 7 percent of the population. They claimed that radiation exposure qualified them for some form of social protection including cash subsidies, family allowances, free medical care and education, and pension benefits for sufferers and the disabled (Petryna, 2004: 255). For Petryna this populations claim exemplifies a new kind of
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biologically defined citizenship. Unlike more conventional claims to citizenship based on appeals to a shared national territory, belief system or culture, here citizenship was scientifically defined and embodied as a degree of radiation exposure. Rose (2007: 133) expands Petrynas analysis to include three separate forms of biological citizenship: (1) individualized biological citizenship, describing how individuals (like Petrynas poterpili) link themselves to their fellow citizens and distinguished themselves from others, non-citizens, partly in biological terms (p. 133); (2) state-led citizenship projects such as public health campaigns, which have linked their conceptions of citizens to beliefs about the biological existence of human beings, as individuals, as men and women, as families and linkages, as communities, as populations and races, and as species (p. 132); (3) collective forms of biological citizenship or biosocial communities (Rabinow, 1996) groups formed around a shared biomedical experience, condition or identity, such as patients organizations or HIV/AIDS campaign groups. In this section, I use the concept of biological citizenship to explore how ontological politics takes place at a geopolitical scale, through the ways in which the state seeks to intervene in the bodies of its population and the ways in which citizens draw on their biological condition to make claims upon the state. I draw on current work in geographies of bioscience and geographies of health to illustrate a shared interest in exploring how biomedicine intervenes in the relationship between citizens/patients and state, generating new possibilities for both state regulation and political protest. I also suggest how work in geography might complement and extend existing understandings of biological citizenship. Within health geography there is a growing body of work which tracks state-led biological citizenship projects and considers their implications. Like Rose, this work draws on a neoFoucaultian framework to explore how populations
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are governed and how un/healthy bodies within the population are rendered visible (Brown and Watson, 2010). Wainwright (2003) describes how working-class women in Victorian and Edwardian Dundee were placed under constant medical supervision in an attempt to reduce infant mortality rates. T. Browns (2000) study of HIV/AIDS discourse in the UK highlights the citizens responsibility to maintain their health as it was articulated through public health education. Southern (2007: 144) describes the new neoliberal geographies of disability which bring some forms of disability into focus through deinstitutionalization, community care and mainstreaming, while simultaneously implicitly pressurizing impaired individuals to work towards the achievement of accepted norms and to overcome the challenges posed by a troublesome or deviant body. Biological citizenship therefore not only provides the basis for claiming new rights (as Petrynas poterpili do), but also comes with new kinds of responsibilities articulated through new forms of biological governance. The active biological citizen must engage in a constant work of self-evaluation and the modulation of conduct, diet, lifestyle, and drug regime, in response to the changing requirements of the susceptible body (Rose, 2007: 154) or, as the UK National Health Service campaign slogan puts it, your health, your choices (UK NHS, 2009). Braun (2008: 263) draws on Rose to argue that public health has, to an extent, always been a biopolitical exercise, concerned with managing life in such a way as to optimize, even increase, the powers of the states constituent body. He describes how, during the Severe Acute Respiratory System (SARS) coronavirus outbreak in 2003, Hong Kong city authorities used public health campaigns to regulate the bodies of their citizens. Citizens were encouraged to eat healthily and exercise to build up their immunity, to open windows to improve ventilation and to avoid touching their eyes, nose and mouth. For

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Braun such biopolitical interventions are how public health names ontological politics; how it seeks to intervene in things in process and shape how they come to be. Increasingly bioscience plays a key role in sustaining such state-led biological citizenship projects. Southern (2007) and Del Casino (2007) describe how the pharmaceutical industry provides products to help citizens achieve the prevailing ideal of a healthy body, claiming to hold the technoscientific key to eliminating disability or disease; a pill for every ill. Simultaneously, the same companies are expanding their markets by defining one or more ills for every pill: expanding the categories of disability that can be medicated or otherwise manipulated for profit (Southern, 2007: 146) in a process Fox and Ward (2008) term the pharmaceuticalization of everyday life. Del Casino (2007) argues such products work to help individuals realize a healthy norm while simultaneously reconfiguring that norm. For example, sexuopharmaceuticals like Viagra reify particular kinds of masculine identities. Biological citizenship therefore offers a way of exploring how biotechnology, filtered through the political processes of state, individual and collective endeavour, is redefining what it means to be human today (Rose, 2007: 154). At the same time geographers have begun to stress how the benefits of biomedical interventions are unevenly distributed. Kearns and Reid-Henry (2009) criticize ongoing work in studies of bioscience for focusing on innovations (such as in-vitro fertilization) which remain beyond the reach of the majority of the worlds population (see also Braun, 2007; Reich, 2000). High costs, coupled with restrictions on access due to restrictive patents established under World Trade Organization (WTO) Trade-Related Intellectual Property (TRIPS) agreements, often place the latest treatments for conditions such as HIV-AIDS beyond the reach of those nations in greatest need (Craddock, 2007). Equally, there is little incentive for the

pharmaceutical industry to invest in developing an AIDS vaccine with a high potential for saving lives but a comparatively low potential for profits (Craddock, 2007: 1043). The uneven distribution of biomedical goods thereby serves to exacerbate existing geographical inequalities in vulnerability to disease (Gandy, 2008; Ingram, 2009b; Sparke, 2009). Del Casino (2010) draws a striking contrast between the challenges faced by a male living with HIV in Long Beach Los Angeles and those faced by HIV activists in Thailand campaigning against US-led patent legislation which would restrict their access to life-saving anti-retroviral drugs. This work offers a useful starting point for considering how biotechnological interventions operate alongside social, political and economic ones (or the lack thereof) and work through existing forms of geographical inequality: cutting along lines of gender, race and class (Kearns and Reid-Henry, 2009: 561). Here the passage between thoughts (of intervening to improve the health of the population and making profits) and things (such as HIV-AIDS vaccines) raises a more ontological question about how lives are valued (Craddock, 2007: 1054) and asks how far, to whom, and in what ways the rights of biological citizenship are extended. The geopolitical dimensions of biopolitical (non)citizenship are also reflected in the ways in which states seek to intervene (or not) in the health and bodies of those outside their borders. Susan Craddocks work on HIV/AIDS (2000), on public health and disease in San Francisco (2004), and on the re-emergence of tuberculosis in US cities (2008) highlights how health risks are often discursively located in marginalized, immigrant populations. Kearns and Reid-Henry (2009) argue that the discourses of biomedicine echo those of imperialism, seeking to organize and structure our understandings of global health and disease around a single model in which the implicit interests and values of western capitalism are prioritized. Jones (2004: 392) suggests that neocolonial
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moralizing about unfettered African [sexual] activity infuses contemporary HIV/AIDS donor policies, resulting in aid interventions which focus on prevention and education to reduce risky behaviour, as opposed to the provision of low-cost anti-retroviral therapies (ART) to prolong the lives of those already infected. Braun (2007: 22; see also Ingram, 2005) describes how discourses of health security and biological threat underpin extra-territorial moves by the US state to secure national borders against pathogenic agents: the fight must be taken over there before it reaches here. The enactment of ontological politics through biological citizenship is therefore explicitly territorial, and biotechnological innovation leads to the reterritorialization of biological citizenship along national, local, and transnational dimensions (Rose, 2007: 132). State-led versions of biological citizenship may also be contested through the creation of alternative biosocial communities (Rabinow, 1996) formed around a shared biomedical experience, condition or identity, such as national and international HIV-AIDS activist and disability rights movements (Biehl, 2006, 2007; Epstein, 1996; Nguyen, 2005; Shakespeare, 2006). Collective action can involve developing a sophisticated understanding of the scientific and medical debates around a condition, campaigning for better treatments, access to services and an end to stigmatization, and the creation of new kinds of social networks (Chamak, 2007: 90; Del Casino, 2010; Rose, 2007; Rose and Novas, 2005). Digital technologies such as email and the internet often play a key role in generating and maintaining these groups (Rose, 2007: 134135; see also Crooks, 2006; Parr, 2002b). Rose (2007) further suggests that the rights and responsibilities of biosociality are spatially and temporally specific. They build on the architectures of previous political activism, shared notions of citizenship and personhood as well as the availability of certain types of technological communications. Consequently, AIDS biosociality in sub-Saharan Africa is very
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different to that of Paris, San Francisco or London (Rose, 2007: 147; see also Nguyen, 2005; Southern, 2006, 2007). In the Global North biosocial communities play a key role in resisting dominant state-led versions of biological citizenship, such as the clean-cut middle-class figure used to exemplify safe homosexual citizenship in an HIV/AIDS awareness campaign directed at gay men in New Zealand (Southern, 2006). Rabeharisoa and Callon (2002: 63; see also Epstein, 1996) describe how the involvement of patients associations in scientific and clinical research is contributing to the slow emergence of a new model for the production and dissemination of knowledge and expertise. In the Global South innovative Public-Private Partnerships work to develop treatments for neglected, unprofitable diseases (Craddock, 2007) and countries such as Brazil (Chagas, 2009) and Indonesia (Kerry and Lee, 2007) use compulsory licensing under TRIPS to gain the right to produce cheaper generic versions of HIV-AIDS medications and Tamiflu, respectively. Geographers have a key contribution to make in mapping out how biosocial communities are formed in a wide range of different sites, from the cyberspaces occupied by the parents of autistic children to the street protests against US patent regulations in Indonesia. Work to date therefore suggests significant potential for geographers interested in health and biomedicine to track both state-led biological citizenship projects and collective resistance to them. Such work could highlight the ways in which geopolitics is also ontological politics, involving interventions into, and derived from, the bodies and material worlds of its subjects and the possibilities for health, disease, normalization and resistance they contain. At the same time, the critical vital geographical perspective highlights how experiences of biological citizenship are spatially and temporally specific, situated within ideological and politicaleconomic systems that serve to restrain and condition those possibilities.

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III Spaces of care

Despite the oppositional account given above, in practice it is difficult to differentiate a space of biomedicine, on the one hand, and a space of alterity, on the other . . . diseases are experienced across a multiplicity of spaces and through a plethora of practices (Del Casino, 2010: 196). The experience of living with disease is more likely to be shaped by a complex web of formal state and biomedical provision intermeshed with alternative practices, medicines, treatments and discourses (see, for example, Das and Das, 2006; Del Casino, 2010). It is to these more localized spaces of care which I now turn. Within health geography care has been largely interpreted within a relational framework that examines the linkages between health and care-giving, the places in which it occurs and those charged with its delivery (Milligan and Power, 2010: 567). This work is wide-ranging,5 including an attention to where care takes place (Kearns and Gesler, 1998), how people experience these places as (more or less) therapeutic landscapes (Conradson, 2005; Williams, 2002) and the role of the home as a site of care (Williams, 2002; Yantzi and Rosenberg, 2008). Work from a political-economy perspective highlights how broader state and market forces have led to a restructuring of care provision within the Global North, away from formal institutionalized care and towards informal and community-based provision (Williams, 2002), with implications for peoples access to care services (Milligan, 1999). Others have highlighted the gender and ethnic division of labour in care work (Dyer et al., 2008; Williams and Crooks, 2008). In contrast, much of the work within geographies of the biosciences has focused on the sites of new biomedical knowledge production (for example, Greenhough, 2006; Parry, 2004). However, within science studies a number of authors have also looked at patient engagement and care (see, for example,

Callon and Rabeharisoa, 2004; Mol and Berg, 1998). Among these, perhaps the most pertinent work which crosses between science studies and geographies of health care is that of Annemarie Mol (2008; Mol and Law, 2004). In this section I will contrast Mols approach to care, which emphasizes ontological politics, with existing work in health geography on care. In so doing I aim to identify areas of shared interest as well as places where Mols approach might be used to critique existing work on care in health geography and vice versa. Mols (2008) The Logic of Care is an account of an ethnographic investigation into the identification, treatment and management of diabetes in a hospital in the Netherlands. Her analysis is rooted in the conviction (arguably one shared by post-positivist health geography) that experiences of health, illness and their accompanying biotechnological interventions need to be understood as situated and experienced through everyday life, specifically through practices of care. Drawing on this research, Mol challenges the logic of patient choice model currently used in biomedical institutions in the Global North, which casts patients in the role of citizenconsumers able to make informed choices from a range of healthcare services. This logic of patient choice arose as a response to criticisms that previous healthcare practices subjugated the voice of the patient to a paternalistic and authoritarian medical profession. However, Mol argues that by dismissing medical authority as too paternalistic and medical technology as too objective, the logic of choice risks also dismissing the important contributions medical authority and technology make alongside (as opposed to in place of) patients experiences of and knowledge of their condition. Mols alternative to the logic of choice is the logic of care as revealed through the everyday processes through which medical practitioners and patients develop and maintain a diabetes management programme. Mols observations of diabetes consultations suggested
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to her that treatment is neither imposed from above (by patriarchal medical practitioners and irrefutable scientific evidence from medical tests), or decided from below by patients making choices. Instead [t]he art of care is to figure out how various actors (professionals, medication, machines, the person with a disease and others concerned) might best collaborate in order to improve, or stabilize, a persons situation (Mol, 2008: 23). For Mol, then, ontological politics is embodied in the localized negotiations that shape the everyday management of a condition such as diabetes (see also Mol, 1999). Mols analysis of how the management of diabetes is enacted draws attention to the importance of place in ontological politics. She demonstrates that any intervention in health and disease biotechnological or otherwise is best understood through an appreciation of how it is situated within specific socio-material environments and practices of care. Mols work therefore shares an interest with health geographers in bodies in the making (Dyck, 1999) and in material context (Dyck, 1995; Moss and Dyck, 2002). There are clear similarities between Mols focused attention on patients lives and accounts within health geography of the everyday experiences of living with chronic illnesses such as multiple sclerosis (MS) (Dyck, 1995) or myalgic encephalomyelitis (ME) (Moss, 1999; Moss and Dyck, 1996). Mols approach to ontological politics is also embodied. Like Southern (2007), Mol argues that the classical citizen is expected to be able to discipline their body in accordance with social norms, to control, tame or transcend (Mol, 2008: 40) their bodies in ways in which those suffering from chronic illness or disabilities are unable to. Mols critique echoes recent critiques of the social model of disability6 (Shakespeare, 2006) and its failure to address the ontological complexities of living with impairment, aches and pains and urinary tract infections (Shakespeare and Watson, 2002), and bodies and biology (Hall, 1999: 142). For Mol and health geographers such as Dyck (1999) and
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Del Casino (2010) these troublesome bodies are themselves sites of political struggle and resistance. Del Casino (2010: 194) notes how chronic illnesses in particular are often problematic for the biomedical establishments curative logic. Without the ability to cure an illness, medical practitioners are forced to rethink their relationship with patients and their treatment regimes.7 Hence, the woman in Dycks (1999: 133) study of living with MS found that her body became a politicized site of struggle: the chronically ill body acts as an ontological catalyst, initiating a renegotiation of the relationship between patients and medical authorities. Mols work therefore offers a version of ontological politics closer to the carescapes and lived experiences explored by health geographers. There are strong synergies between her approach and the social ontology approach within feminist geography, which understands all social relations as contextual, partial, attentive, responsive and relational (Lawson, 2007: 3). However, Mol departs from other social science and health geography accounts in refusing to set biomedical knowledge and technologies in opposition to notions of care. Where Dyck (1999) and Del Casino (2010) emphasize the material body as a site for resisting dominant biomedical discourses, for Mol the body becomes a site where biomedical knowledges are enacted alongside other ways of knowing the body in ways which complicate and disrupt any knowledge hierarchy. Thus, Mol (2008: 1) argues that even if the interventions in the lives and bodies of people with chronic diseases are often knowledge intensive and technology dependent, there are good reasons for calling them care. Mol (2008) recognizes peoples assertive approach to their relationship with biomedicine and their sense of working in partnership with medical staff and technologies (see also Clarke and Newman, 2007). This perspective is echoed in geographical analyses of the relationship between biomedicine and Complementary and Alternative

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Medicine (CAM). Like Mol, Wiles and Rosenburg (2001: 222) suggest that biomedical practice does not operate in some kind of social vacuum and people are not passive victims of a patriarchal biomedical authority. Patients may choose to consume healthcare outside the formal biomedical spaces of provision not just as a reaction against biomedicine, but as a means of asserting identity, of maintaining power and control over the self and decisions made about the body, or exploring out of curiosity (p. 222). Accounts of how care takes place within health geography might therefore be expanded to account for the caring roles played by biomedical knowledges and technologies. BoswellPenc and Boyers (2007) account of how American women use breast pumps to manage their dual commitments to work and childcare provides one example of how such work might take shape. Parrs (2002b) and Crooks (2006) analyses of the role of internet technologies in helping patients manage their experiences of disease provide another. Perhaps the most detailed example comes from Halls (2004) analysis of how genetic technologies and knowledges are incorporated in general practitioners (GPs) consultations with heart disease patients. Drawing on ANT, Hall stresses how the geneticisation of heart disease is neither uncontested nor inevitable (Hall, 2004: 313). Instead the incorporation of genetic knowledge into heart disease consultations needs to be understood as part of a complex and contested negotiation between patients and medical professionals, supported (or not) by the results of diagnostic tests, on an individual, case-by-case basis. Hall (2004) concludes that geographers have a key role to play in mapping out how the geneticization of heart disease (and arguably other intersections between biomedical technologies and health care) takes place in different contexts. At the same time Mols focus on how care is negotiated within the hospital setting leaves open the question of how practices of care (or the lack thereof) are experienced in other sites and

spaces. This is an area where geographers have much to contribute in analysing how care is negotiated within (or excluded from) the workplace (see, for example, Boswell-Penc and Boyer, 2007; Hall, 1999; Moss and Dyck, 1996), the home (Williams, 2002) or the respite centre (Conradson, 2005) and how the creation of therapeutic spaces for the care of one person can simultaneously produce highly stressful and untherapeutic spaces for those charged with their care (Williams, 2002). Takahashi et al. (2001) highlight daily routines and practices to show how the individuals in their study managed living with HIV-AIDS, expanding a focus on care into an attention to the worlds of patients (Philo, 1997: 83). Takahashi et al. share Mols interest in how technical processes and material constraints such as following complex drug treatment regimes can intersect with social ones. Unlike Mol, however, Takahashi et al. focus less on the quality of care, and more on issues of access to care services (see also Milligan and Power, 2010). Their concern with access highlights how Mols study, where good practices of care seemingly dominate and access has already been achieved, is one specific case and best as a point of critical comparison rather than a model from which generalizations can be derived. Questions of access are also raised when we ask how far the kind of good care Mol emphasizes, which depends on localized, often face-to-face negotiations, may or may not be able to function at a distance (Massey, 2004). For Mol, then, good care is both ontological and political. It involves relations between bodies and machines as well as doctors and patients, and it involves not a single authority proclaiming a solution, but a continuing process of (re)negotiation (politics at the micro-scale) between all the different agencies involved. Mols work therefore suggests possibilities for combining an attention to the spaces of care with an appreciation of the role of human and non-human elements (including biomedical technologies) in shaping those spaces and relations and the
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political possibilities they contain. At the same time, work in health geography serves to highlight (as Hall suggests) the need to place such accounts in context. We need to recognize that the same negotiations and technologies that create spaces of care for one person may disrupt and disturb the spaces and routines of others, and that not all have equal access to spaces and technologies of care.

IV More-than-human companionship
Mols emphasis on the role of non-human elements in shaping the geographies of health and biomedicine also introduces the third site of ontological politics I wish to explore here, the interface between humans and other species. Within health geography, there have been some attempts to engage with the non-human elements of therapeutic landscapes (Conradson, 2005), but such studies tend to focus on how humans experience those environments, rather than the role of non-human agents in shaping them. In this final section, I suggest that Haraways (2008) approach to ontological politics, as exemplified by her recent book When Species Meet, might provide an alternative basis for comparison in exploring the role of non-human agency in geographies of health and biomedicine. For Haraway ontological politics involves acknowledging the openness of our corporeal selves to the bodies and beings of others. In Hinchliffe and Binghams (2008b) words, Haraway proposes an alternative body politic to the neoliberal biopolitical citizen who is self-contained, healthy and alert. The bodies of Haraways companion species are inseparably networked within wider biological, social, political and economic structures, vulnerable and permeable to infections and penetrations of all kinds. This perspective is echoed by the work of health geographers who stress that diseases are biological as well
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as social processes (M. Brown, 2006; Del Casino, 2010; see also Mol and Law, 2004). For example, M. Brown (2006: 894) suggests that we need to move from focusing on public imaginations about sexually transmitted diseases and their populations to recognizing the spaces in which sex occurs and noting the relations inherent in sex and sexuality. It is these spaces, with their specific political ecologies of disease and complex human human and humandisease interactions where the most meaningful and effective interventions should they be needed might be made. This attention to the body as a physical object provides a starting point for thinking through how geographies of health and biomedicine are more-than-human geographies (Whatmore, 2002). They move beyond the more familiar understandings of the human being as a citizen or patient, a social subject, and towards understandings of the human being as a fleshy, biophysical object. Haraway, however, would perhaps find M. Browns analysis anthropocentric. For Haraway, citizenship is not something confined to the human, but rather something that occurs across species and ties many knots between them (Haraway, 2008: 118). Where M. Brown focuses on the human body at risk of Sexually Transmitted Infection (STI), for Haraway the human is not the only being at stake. Her work highlights how our epidemiological heritage and experiences of health and disease are closely and inseparably intertwined with those of companion species, who, through long histories of domestication and co-habitation, have evolved with and through us. For Haraway, the history of the flu is unimaginable without the concept of the co-evolution of humans, pigs, fowls and viruses (Haraway, 2008: 31). This is also a key theme in recent geographical work on biotechnology, which stresses how both human and animal environments, as well as the relations between them, are transformed by biotechnological and biomedical interventions (see, for

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example, Morris and Holloway, 2009; Whatmore, 2002). For geographers, who have a long history of critically interrogating relations between nature and society, there is fertile ground here for drawing some of the insights from animal geographies into geographical studies of biomedicine, health and disease. Like Haraway, geographers have noted the close intertwining of human and animal lives (Philo and Wilbert, 2000), and Lawson (2007: 6) suggests that in developing geographies of care we need to pay attention to crucial issues of the intimate connections between care of both humans and the nonhuman. Braun (2008) highlights how viruses are active agents in shaping histories and geographies. He describes how the 1012-day incubation period of SARS played a key role in facilitating its rapid transmission though international travel systems: infected individuals could travel across the globe before any symptoms were detected, spreading the infection to others. Recent work in political ecology suggests a need to recognize how the complex interplay of politics, markets and ecologies is generating new breeding grounds for viruses through the creation of industrial farming complexes in low-income countries poorly equipped to monitor animal health (Wallace, 2009; see also Jackson, 2008). Geographers have also been at the forefront of emerging work on biosecurity. Hinchliffe and Bingham (2008a; see also Hinchliffe, 2001) note how zootonic8 diseases challenge our practices of co-habitation and the conditions under which we keep and live with animals. The threat of avian influenza led not only to a renegotiation of human lives (through practices of quarantine, vaccination, treatment and surveillance), but also to a critical revaluation of the ways in which we live with non-human others.9 Braun (2008) suggests that outbreaks of epidemics like SARS or avian influenza reveal the inadequacies of our current ontological imaginations which see nature as absent from urban space; imaginations supported by architectures that bury evidence of

biological systems and processes (Gandy, 1999) and exclude livestock from the city (Philo, 1995). To counteract this, we need a new ontology of city life that recognizes the deep intertwining of human and animal lives (Braun, 2008). Haraway, however, goes further, suggesting we must also become response-able towards our companion species. Here responsibility is understood in its widest sense as being response-able: able to sense and respond to the needs of another. This form of response-ability is, importantly, not just articulated through language but through the bodily movements, gestures and comportment which signal an animals distress or a childs hunger. Haraways emphasis on non-verbal forms of cross-species communication offers a new model for understanding how we relate to others within our own species, including the kinds of non-verbal, embodied, somatic sensibilities that good care may entail. This is a theme picked up by Mols (2008) description of how clinicians:
diagnose with their senses. They notice posture, muscle tone and bruises; they hear sadness in a tone of voice or the signs of impaired breathing; they feel for the pulse, for lumps; and they may smell metabolic disturbances. (Mol, 2008: 39)

It is an approach that resonates with recent work in geography on embodiment, affect and practice (Andersen, 2006; Thien, 2005) and shares a relational ontology that privileges intimacy and proximity (Pile, 2008). It also resonates with the increasing sensitivity of health geography to the embodied nature of disease experiences experiences that often cannot be put into words (Parr, 1998: 343; see also Dyck and Kearns, 1995). Perhaps the closest approach to Haraways work in health geography is found in Mosss (1999: 159) accounts of living with ME, where she describes ways of knowing and being that have been heightened sensually because of my illness. For some biosocial activist groups, such as the autistic culture movement (Sinclair, 1993), this kind of differential sensitivity can form the
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basis for claiming that their condition is not a disease, but a new form of culture or identity. Joyce Davidson (2007, 2008) suggests the autistic culture movement goes beyond biological citizenship, highlighting how autistic culture and the response-abilities it generates become the basis for demanding ways of making space for and legitimating autistic experience and expression that involve much more than adaptations for physical access (Davidson, 2008: 800). For Moss and the autistic culture movement, Haraways work draws attention to how ontological sensitivities become a corporeal basis for renegotiating encounters with the world. For Haraway, though, response-abilities cross species boundaries. This concern is echoed in geographies of nature and biotechnology which recognize how biotechnology is redefining our (ethical) relations to non-human others (Whatmore, 1997). Mosss account of how living with disease changed the nature of her encounters with the world can be contrasted with the work of the animal scientist Temple Grandin. Grandin draws on her autism, and the sensory sensitivities it gives her, to claim she has a distinctive way of engaging with the world and other species within it. Grandin suggests that many or even most autistic people experience the world a lot the way animals experience the world: as a swirling mass of tiny details. Were seeing, hearing and feeling all the things no one else can (Grandin and Johnson, 2006: 67). A biological citizenship approach might see Grandins supersensitivity as a basis for claiming personal rights, privileges or compensation, or a justification for others imposing responsibilities on her to manage her distinctive neuroatypical ontology. Grandin instead suggests her autism entails responsibilities towards others, towards companion species, and uses her autistic sensitivities to inform innovations in animal welfare, including the redesign of slaughterhouses to lessen animal stress (see Grandin and Johnson, 2006). Geographers, in asking about how illness changes our relations with the
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world, might also address how it changes our connections to non-humans within it. Haraways approach to ontological politics therefore highlights, as Rock et al. (2007) note in a recent editorial in Social Science and Medicine, how animals are involved in practices of medical research and healthcare in complex and often contradictory ways. We are dependent on non-human others as the assayers of our biomedical treatments. We are placed at health risk by the practices of co-habitation through which we share spaces and diseases with companion species. Yet at the same time we look to companion species for comfort at times of illness and distress. There is work here for geographers in mapping out how bioscience intervenes in the already complex intertwining of human and non-human worlds generating new ontological sites of political obligation. Davies (2009) current research project on the creation of humanized mouse models10 for human diseases provides an example of how such work may proceed. At the same time Haraways notion of response-ability also points to a role for health geographers in exploring how embodied experiences of health and disease entail renegotiations of our relations with non-human others, and new ways of being affected by and responding to these.

V Conclusion: Towards an ontological approach to geographies of health and bioscience

At the start of this paper I suggested that geographies of bioscience and health geography share interests in engaging critically with biomedicine and biotechnology and in ontological politics engaging with the material world as a starting point for gauging political effects and finding new political possibilities. I suggested that these shared interests might form a basis for a collective research agenda between the two subdisciplines. In setting out this agenda I have used a

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framework based on the different sites and spaces where ontological politics might take place, taking inspiration and conceptual resources from ongoing work in geography, sociology, anthropology and biophilosophy. These sites and spaces are less locations and more defined by particular kinds of encounter: between states, markets, biomedicine and citizens (biological citizenship); between care providers, biomedical technologies and patients (spaces of care); and between (companion) species. They also represent different scales at which ontological politics may take place, ranging from the geopolitical, to the local, to the corporeal. By exploring ongoing work within geographies of health and the biosciences in each of these sites, as well as work outside geography, I aimed to identify synergies between research projects already being undertaken and to suggest new spaces for collective research endeavour. In concluding, I will briefly revisit each of these sites, summarizing the kind of ontological politics they present, work in this area to date both within and beyond geography, and emerging areas for collective research. First, Petrynas (2004) and Roses (2007; see also Rose and Novas, 2005) concept of biological citizenship highlights how ontological politics takes place at the interface between body, citizen, science and state, creating new networks and territories that link individuals, communities and governments for example, the state-led citizenship projects that seek to regulate the health of the population, or the online cyberspace communities which form new sites for patient activism and political protest. The survey above suggests that the work of geographers can both complement and extend these observations by offering substantive evidence of how experiences of biological citizenship are temporally, socially and geographically contingent. Perspectives from critical geopolitics (Braun, 2007; Kearns and Reid-Henry, 2009) also indicate a role for geographers in questioning the inequalities which differentiate between those who are

in a position to benefit from biomedical innovations and those who are not, as well as the dominant western biomedical discourses which can exacerbate such inequalities. Mols logic of care provides an interesting contrast with previous work on care within geographies of health. For Mol, ontological politics takes place through the localized spaces of the hospital, the clinic and the living room, and is enacted through the ways in which patients negotiate living in the world with a medical condition. Her work therefore has close synergies with health geographers interests in embodied experiences of health and illness and how these shape everyday life. At the same time Mol questions the often implicit assumption within health geography that biomedical interventions are irreconcilable with good care. Mol argues that biomedical technologies and authorities make up a key component of the wider network of people and other agents through which care takes place. Health geographers in turn might question the extent to which the same negotiations which create spaces of care for one person may disrupt and disturb the spaces and routines of others, and point out that not all have equal access to different spaces of care. Health geographers have a key role to play in mapping out how intersections between biomedical technologies and health care take place in different contexts (Hall, 2004). For Haraway, ontological politics involves the creation of novel body-environment ontologies, where medical conditions mark the starting point for developing new embodied ways of engaging with the world and other species within it. Here her work resonates both with work in health geography concerned with disease as an embodied, biophysical experience (M. Brown, 2006; Del Casino, 2010) and work within geographies of nature-society relations which tracks political-ecologies of disease and the bio(in)securities these raise (Braun, 2008; Hinchliffe and Bingham, 2008a; Wallace, 2009). Her concept of response-ability provides an interesting point
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of connection between these two fields, focusing on how the body (and its ability to sense and respond to human and non-human others) acts as the site for generating new ethical and political relations with the world. This is captured in the work of Pamela Moss and members of the autistic cultures movement who describe how ME or Autism Spectrum Disorder (ASD) can change how we sense and respond to the world and other species within it. For geographers engaged at the borders between science studies and health geography, Haraways work offers some important considerations to take forward. Notably the ways in which biomedicine and scientific interventions not only define disease, but offer new models of the ways in which bodies encounter the world, marked by different kinds of response-abilities and different sets of political and ethical rights and obligations. Equally, as well as mapping out how ontological politics takes place at different sites and scales, geographies of health and biomedicine might also productively explore the interconnections between them. For example, how do the biomedical interventions made to promote and ensure certain forms of biological citizenship at the national scale, such as national cancer screening programmes or the provision of ART, intervene in the localized spaces of care described by Mol? To what extent can the geopolitical critiques levelled at geographies of bioscience also be levelled at geographies of health care, which for the most part focus on the Global North (although see Del Casino, 2010; Robson, 2000)? To what extent can the kinds of interspecies response-abilities described by Haraway, which often rely on affective responses and close proximity between actors, operate at a distance (Greenhough and Roe, 2010; Massey, 2004) and be used to rethink the ethics and welfare policies of multinational pharmaceutical firms? Focusing on the material and ontological dimensions of these cases (screening machines, drugs, healthcare infrastructure in the Global South and humanized mice) provides one
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starting point for mapping out their political possibilities and effects, and how these both generate and reflect spatial relations. I would like to end by returning to the two claims that I made at the beginning of this piece. First, I suggested that a focus on ontological politics provides a means of connecting the concerns of health geography to critical geographies of the biosciences. I hope through the three sites mapped out above I have offered some insight into the kinds of connections possible (citizenship, care, companionship) and the different sites and scales (geopolitical, local and corporeal) which could form the focus of a collective research agenda. These examples illustrate how an attention to the material sites of biomedical intervention gives us new insights into its political effects and possibilities and how these shape and are shaped by relations between health and place. Second, focusing on ontological politics highlights the connections between ongoing work in geographies of health and the biosciences and work outside the discipline. Drawing on the work of Rose, Mol and Haraway in particular, I have identified areas of shared concern (biological citizenship, spaces of care and relations with companion species) which bridge work in geographies of health and bioscience and work in social studies of science, medical sociology and anthropology. Finally, I have suggested that geographers have a key contribution to make in addressing these concerns: stressing geographical inequalities in biological citizenship; examining contextual differences in experiences of care and biomedical technologies; and exploring how geographies of health and biomedicine intervene in corporeal relations between companion species. Acknowledgements
This work has been in part inspired by discussions with reading groups on Haraway (UCL, 2008) and Mol (Reading, 2009), and with my colleagues Emma Roe (Southampton) and Jane Wills (QMUL). Thanks go to Isabel Dyck, Roger Lee, three anonymous

Greenhough referees, and the editors for comments on earlier drafts of this paper.

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7. It is interesting to note that both Mols work and much of the work on embodiment within health geography share a focus on chronic illness, given the challenge to biomedical authority Del Casino (2010) suggests it provides. This leaves open the question of how spaces of care may take shape differently when looking at short-term or treatable conditions. 8. Zootonic diseases are those which can pass between humans and animals, such as H1N1 (swine flu). 9. Hinchliffe and Bingham (2008a) give the example of the Egyptian ban on backyard domestic poultry keeping. Prior to the ban, which was a response to the threat of avian influenza, backyard poultry had been a key source of cheap protein for many families. 10. Humanized mouse models are mice which have been modified to carry human genes, cells or tissue for the purposes of modelling human diseases and developing new therapies.

Funding
This research received no specific grant from any funding agency in the public, commercial, or notfor-profit sectors.

Notes
1. With the exception of a shared interest in Foucault (see T. Brown, 2000; Brown and Watson, 2010; Philo, 2000; Rose, 2007). 2. Notable exceptions include M. Brown (2006), Craddock (2008), Davies (2006), Del Casino (2010) and Hall (2004). 3. This is not to imply that this is the only approach to rethinking the politics of science and medicine. For example, within both science studies and health geography a feminist perspective has also been productively employed as a means of critiquing dominant modes of social and political relation and generating new political standpoints. See Dyck (1999) and Moss (1999) on health geography and Haraway (1991) and Harding (2006) on science. 4. Ingram (2009a) suggests the use of the term geopolitics in discussions of disease (and health) usually refers to three main themes (all reflected here): the way in which disease is governed through spatial practices, biopolitics (political interventions which seek to secure the health of the population), and the politicaleconomic relations which produce health inequalities. Suggesting biological citizenship operates at a geopolitical scale implies it is caught up in producing and responding to these themes for example, through the ways in which biopolitics produces particular forms of state-defined biological citizenship and the ways in which health inequalities determine who has access to the rights and responsibilities of biological citizenship. 5. For overviews of work in health geography on geographies of care, see Milligan and Power (2010) and Parr (2003). 6. The social model of disability (Oliver, 1990) resisted biologically defined notions of difference and impairment, claiming instead that it is the way in which social and material environments are designed in response to a perceived bodily norm that actively disables people (see, for example, Butler and Bowlby, 1997).

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