Chapter 7: Power and Politics of Health An Introduction to the Geography of Health Source: CDC (1980)

2 An Introduction to the Geography of HealthAnthamatten and HazenChapter 7 Power is often conceptualized by drawing attention to the ways in which structures of society, and who controls them, can influence individuals and groups. Social scientists often consider how human agency, or the power an individual has to control a situation, is constrained by these structures of society. Structural Approaches to Power and Health

3 An Introduction to the Geography of HealthAnthamatten and HazenChapter 7 Political economy approaches to health recognize the importance of political and economic structures in constraining and enabling human activities that influence health. A political economy approach might focus on colonial power structures as a means of understanding AIDS, for example. Can you think of how a history of colonialism could have an effect on contemporary patterns in disease?

4 An Introduction to the Geography of HealthAnthamatten and HazenChapter 7 Related to political economy, are political ecology approaches, which consider the ways in which structures of power and the environment are interrelated. Political factors such as capitalist economic structures, colonial histories, and social relations of production can influence ecological access and environmental change. How is political ecology relevant to the geography of health?

5 An Introduction to the Geography of HealthAnthamatten and HazenChapter 7 Examples of health geography studies in political ecology include: How has Africa’s refugee crisis affected emerging infectious disease? (Kalipeni and Oppong 1998) How have historical, social, political, and economic processes contributed to high levels of lead poisoning in parts of the US and North Carolina? (Hanchette 2008) How have women been disadvantaged by Bangladesh’s arsenic- contaminated water? (Sultana 2006) What are the impacts of AIDS in Africa on social and environmental systems? (Barnett and Blaikie 1992)

6 An Introduction to the Geography of HealthAnthamatten and HazenChapter 7 Another way in which power can be conceptualized structurally is by considering the impact of politics— the ways that groups of people make decisions to formulate policy—at different scales. Politics and Health

7 An Introduction to the Geography of HealthAnthamatten and HazenChapter 7 Politics can have an impact on spatial and social aspects of health, both by driving how healthcare is funded and administered, and through regulating health-related behaviors. Can you think of examples of how health behavior is regulated in your country or community? Photo by Muslimgalerie Bouh

8 An Introduction to the Geography of HealthAnthamatten and HazenChapter 7 While the role of government provides a clear example of how power can influence health, critical geographers and other scholars have emphasized that power differentials also characterize everyday interactions related to health. For instance, power dynamics characterize the relationship between patient and doctor, and people can be “othered”—or systematically marginalized by society—on the basis of their health. New Geographies of Power

9 An Introduction to the Geography of HealthAnthamatten and HazenChapter 7 Key fields of research in these new critical geographies include: Segregation and health: How certain groups of people, such as the infectious, the mentally ill, or the homeless, are systematically marginalized from society. Power and the body: How struggles for power occur at the scale of the body. Surveillance and public health: How biomedicine is increasingly intervening in the lives of not only the ill, but also the well, in surveying and regulating behavior.

10 An Introduction to the Geography of HealthAnthamatten and HazenChapter 7 Fertility policy is a common way in which governments intervene in individual health decisions. Governments may have social or economic reasons to implement anti-natalist (discouraging fertility) or pro-natalist (encouraging fertility) policies. Fertility Policy Why might a government wish to adopt either a pro-natalist or anti-natalist policy?

11 An Introduction to the Geography of HealthAnthamatten and HazenChapter 7 Fertility policy can be examined from a power perspective. A key distinction is often made between policies that promote contraceptive technologies in order to empower people to control their own fertility, and others that seek to control the fertility of certain groups within a society. Data Source: UN (2009), UNDEP (2009)

12 An Introduction to the Geography of HealthAnthamatten and HazenChapter 7 Critics of international population campaigns have argued that Western interests, often with the support of elite policymakers, have aggressively promoted family planning in the low-income world as a way to reduce population growth in these regions rather than to promote reproductive choice. Slowing population growth is often a geo-political, ecological, and/or resource-related goal. Is it appropriate for the Western world to try to influence fertility policy in the low- income world? Why or why not?

13 An Introduction to the Geography of HealthAnthamatten and HazenChapter 7 China has experimented with some of the most aggressive family planning policies, lending its story particular relevance to the study of geographies of power. China’s fertility policies may have prevented 250 million births over the last 25 years (Zhengming 2000). Family Planning in China

14 An Introduction to the Geography of HealthAnthamatten and HazenChapter 7 China’s policies have focused on: 1)delaying marriage and childbearing, 2)birth spacing, 3)fertility limitation. Preferential treatment in education and health has been provided for only children, while penalties for non- compliance have included large fines. Stringent social and administrative control in China has enabled the implementation of these policies.

15 An Introduction to the Geography of HealthAnthamatten and HazenChapter 7 Compliance with and acceptance of family planning policies varies considerably across China. Source: Attané (2002) Reproduced by kind permission of Wiley-Blackwell.

16 An Introduction to the Geography of HealthAnthamatten and HazenChapter 7 A population pyramid can shed insight into population policies. The large base of the pyramid, indicating a high birth rate, clearly shows why China was interested in maintaining its anti-natalist policies in Data source: US Census (2009)

17 An Introduction to the Geography of HealthAnthamatten and HazenChapter 7 The impacts of China’s fertility policies are clearly visible in the narrowing base of this population pyramid from Data source: US Census (2009)

18 An Introduction to the Geography of HealthAnthamatten and HazenChapter 7 China’s fertility policies may pose problems in the future as China’s working population shrinks. This pyramid, showing China’s projected population structure for 2050, illustrates how a large elderly population must be supported by a shrinking working population. Data source: US Census (2009)

19 An Introduction to the Geography of HealthAnthamatten and HazenChapter 7 Conclusion Health and healthcare decisions are infused with power. Whether at the scale of international debates regarding fertility, national decisions over smoking policy, or an individual’s discussions with her doctor, investigating the impact of power relations is critical.

20 An Introduction to the Geography of HealthAnthamatten and HazenChapter 7 Discussion Questions 1.Which is more important: public health or the rights of the individual? Do governments have a responsibility to regulate dangerous behaviors such as smoking? To what degree does the state have the responsibility or the right to regulate behaviors that may lead to the transmission of disease? 2.In what way do spatial patterns and processes illustrate or reflect issues of power? How is the notion of “territory” significant to health? 3.Are coercive family planning measures ever warranted? 4.Is family planning in low-income countries an effort to curtail non- White fertility, or do policies reflect a genuine concern for the well- being and health of people throughout the world?

21 An An Introduction to the Geography of HealthAnthamatten and HazenChapter 7 References Attané, I. (2002) ‘China's family planning policy: an overview of its past and future’, Studies in Family Planning, 33: 103 – 13. Barnett, T. and Blaikie, P. M. (1992) AIDS in Africa: Its Present and Future Impact, New York: Guilford Press. [CDC] Centers for Disease Control (1980) “Image ID# 8195” Public Health Image Library [Online]. Available: (Accessed 10 Jan 2011). CDC / Barbara Jenkins, NIOSH. Photograph by Roy Perry. (1946) “Image ID# 8956” Public Health Image Library [Online]. Available: (Accessed 02 Jan 2011). Hanchette, C. L. (2008) ‘The political ecology of lead poisoning in eastern North Carolina’, Health & Place, 14: 209 – 16. Kalipeni, E. (2000) ‘Health and disease in southern Africa: a comparative and vulnerability perspective’, Social Science & Medicine, 50: 965 – 83. Sultana, F. (2006) ‘Gendered waters, poisoned wells in Bangladesh’ in: Lahiri-Dutt, K., National Institute for Environment, and Australian National University (eds.) Fluid Bonds: Views on Gender and Water. Kolkata: Stree. United Nations. (2009) World Population Prospects: The 2008 Revision, Executive Summary [Online]. New York: United Nations. Available: (Accessed 27 December 2009). [UNDEP] United Nations and Department of Social and Economic Affairs. (2009) World Population Prospectus: The 2008 Revision Population Database [Online]. Available: (Accessed 3 January 2010). US Census Bureau (2009b) International Database: China population data, 1990, 2009, Zhenming, X. (2000) ‘Population policy and the family-planning programme’ in: P. Xizhe & G. Zhigang (eds.) The Changing Population of China. Oxford, UK: Blackwell.