A meadow in winter, a garden in spring

In the mornings, the North Kelvin Meadow is a calm place, periodically enlivened by dog walkers and people passing through as a shortcut to destinations both nearby and further afield in Glasgow. A mother and daughter pass through on the way to school, greeting the dogs. For them, passing through creates a break between the clamour to leave the house and the pressures of work and school. Others climb through the gaps in fences or walk between cheerfully painted bollards to sit among the trees reading a newspaper in a slither of sunlight coming through the branches of the birch trees. For some the meadow is a place to linger, to embrace the slowness of seasonality; or to speed up the boredom of having little to do. In the summer, the meadow's tree-lined edge blocks out the surrounding houses, lending the space a sense of disconnection from the rest of the city. In the middle of the meadow, it opens out: raised beds along one side and into the corner, open grass in the middle, worn through by use in places to its previous red, crumbling sports surface.

In my early research encounters with the meadow in December 2014, it was brittle with frost, the ground hard and the days short. Walking through with a local campaigner and long-time resident, Alasdair, who insisted that we leave the warmth of his flat where we were talking to take in the meadow around the corner in the early dusk of mid-winter, we spontaneously met others who wanted to talk about old shell casings found on the meadow, the history of the space. Alasdair was enthusiastic, garrulous even, in spite of the freezing temperatures. I had initially reached out to him to discuss the meadow's fight against the sale of the land for development but Alasdair insisted that to understand the space and its value, I had to appreciate its rich, common ordinariness in person and immediately. As he put it, “It's communal, everyone's entitled to use it.” In the meadow, the intertwined threads of mundane use and political campaigning against its development highlight critical tensions around who makes the city and how it might be remade and reimagined.

The meadow is embedded in the rhythms of everyday life for many local people; an everyday green space in the fabric of the city.

Like ‘littering in your back garden’

On a mild June evening, Terry, a couple of well-dressed visitors from the local Green Party branch and I spend a few hours wandering around the meadow. It is a tour of sorts, so Terry is in tour guide mode, explaining the history of the site and what the North Kelvin Meadow campaign stands for and how it is shared and managed. One story that he tells, pointing to the space around us, is of an absence – a notable lack of rubbish. Terry says, people do not tend to litter much and people often pick up anything they see on the ground. He goes on to say that the mindset of kids on the site is interesting: they pick up on “the community aspect” of it, and instead of dropping things, they hang on to them. Terry then points out that there is this sense that if they littered here they would be pissing off their parents. For them, Terry argues, it just would not make sense to litter here. One of the visitors nods along and makes the comparison to “littering in your back garden”.

Terry agrees, and claims that at the nearby Glasgow Botanical Gardens they have eight or nine people employed to keep the space pristine and litter-free. Because of a shared relationship to the land and to the people who use it (implicitly absent in his account at the Botanical Gardens), Terry thus weaves a story about how people are inhibited from littering.

A sense of ownership is undoubtedly important in this specific iteration of community, but this also highlights the way community as a frame gets used to explain things at the meadow, in this case, a dearth of littering: the resonance of the idea of community, of being part of a collective, is argued to work against practices of misuse, like littering and arson. What is elided in Terry's account into a simply community ethic is that litter-picking is a common enough activity, especially before toddler groups. Someone usually checks the area for left-behind bottles, cigarette butts or other miscellaneous rubbish before toddlers use it. This is an important grounding to this otherwise glorious vision of communality: it might well inhibit littering, but it also involves an active practice of litter removing.

This chapter looks at the remit of, and the activities engaged in by, different organizations and groups involved in global health. These include major world organizations (notably the World Health Organization and World Bank), constellations of public– private partnerships, non-governmental organizations and social movements. It also examines the role of philanthropy, asking whether it is more appropriate to speak of “philanthrocapitalism”.

Wrapped up in the geopolitics of health are issues of global health security: issues that have inevitably come to the fore during the Covid-19 pandemic but that emerged some years earlier when new strains of influenza were appearing and the earlier coronavirus infection (severe acute respiratory syndrome: SARS) appeared on the world scene. The second half of the chapter therefore explores what is meant by health security.

As the quote at the start of the chapter suggests, we need to examine the relative power of the different agencies involved in global health, and where power lies in determining who gets “secured”, how and where.

Governance

My focus here is on relations between the actors involved in global health – nation states and organizations of different types – and less on the governance within states or organizations. The latter matters greatly, of course. For example, there is a close relationship between maternal mortality rates among a set of 174 countries and indicators of their governance (government effectiveness, regulatory quality, rule of law, control of corruption, voice and accountability, and political stability and absence of violence – all indicators proposed by the World Bank) in those countries (Ruiz-Cantero et al. 2019). The stronger the governance, the lower the rate of maternal mortality.

As well as exploring the roles of nation states and major intergovernmental organizations, the governance of global health is seen as “stemming from a configuration of public private partnerships (PPPs) between governmental agencies and programs, NGOs and charitable foundations, including the omnipresent Bill & Melinda Gates Foundation and other “philanthrocapitalists” entwined with the neo-liberal order” (Lovell, Read & Lang 2019: 522). Each of these actors – and the relations between them – is discussed in this chapter.

In their introduction to health geographies, Brown et al. (2018) refer to “five cross-cutting critical themes” that thread throughout their chapters. In a book on global health it is inevitable that my own choice of cross-cutting themes overlaps with theirs, but the material I have covered leads me to suggest some alternatives (Table 10.1).

In this concluding chapter I want to use these themes to summarize what has been presented in earlier chapters.

Governance/security

Power, whether political or economic, is held by a wide range of actors – individual, organizational, state or international – with complex relations between different levels. Actors can include NGOs, government departments, private companies, landowners, and so on. All these, often networked together, dictate access to resources, including healthcare, that in turn shape health or its absence. The power contained within these networks may contribute to structural violence, as noted later. Yet states and international organizations alike can, as Farmer (2005: 142) has pointed out, be relatively powerless.

We saw in Chapter 3 that there is a debate among political geographers and international relations researchers as to the relative power exercised by the state and international bodies such as the WHO, notably in addressing infectious disease spread. The Global Health Security Index remains resolutely fixated on security from infectious disease. But countries in the Global North have their own, internal, issues of security.

Climate change is but one component of a set of wide-ranging human impacts on the environment, which also include urbanization, land use change and loss of biodiversity, deforestation, resource extraction on land and in the oceans, the growth of agribusiness, and conflict. It must therefore be borne in mind that climate change is part of a complex system of environmental disturbance and perturbation. The introductory quote by Merrill Singer makes it quite clear how embedded is the deeper structure of this complex system. The present chapter seeks to show how the climate crisis is also a health crisis.

There is abundant evidence of long-term climate change. For example, the United Kingdom's Meteorological Office reported in May 2022 that climate change has increased by 100-fold the chances of record-breaking heatwaves in northwest India and Pakistan; a heatwave (of more than 50°C) is projected to occur every three years (Met Office 2022). There was a fivefold increase in exposure to extreme heat events between 1980 and 2017 for the world's most populated cities, and current exposure to heatwave events is almost 15 billion person-days per year, with the greatest cumulative exposures occurring in southern Asia (7.19 billion), sub-Saharan Africa, and north Africa and the Middle East (Met Office 2022).

Any discussion of the impact of climate change on human health must begin with the monumental report from Working Group 2 of the Intergovernmental Panel on Climate Change (IPCC), which was delivered in February 2022 (IPCC 2022). At 3,675 pages this report is truly encyclopaedic, but the “Summary for policymakers” is an excellent starting point. My own focus is initially on impacts on vector-borne infectious disease (malaria and dengue), waterborne disease, nutritional deficiencies and food security. I then consider impacts on Indigenous groups before looking at the consequences for population displacement and migration. The latter, as with so much else on climate change, makes highly visible the “geographical connections” in this book title.

I noted in Chapter 1 that the essence of globalization lies in the various interconnections and interdependences across borders. These networked connections involve mobility, whether of goods, money, services, information or people. Such flows are the focus of this chapter and two of the next. In the present chapter the focus is on movements of people and the associated health impacts. Later chapters examine movements of materials – focusing less on the trade in goods and more on the flows of “bads” – and then infections.

In a very prescient observation ten years ago, Glick Schiller and Salazar (2013: 184) wrote that “the current global economic crisis seems to be accompanied by a normalisation – once again – of national borders and ethnic boundaries, even as the crisis itself reveals the degree to which the world is intricately networked and interdependent”. The connections afforded by globalization seem – after the Russian invasion of Ukraine, as well as Trumpian politics and Brexit – to be giving way to heightened nationalism. Despite these borders, desperate people will continue to seek safety and refuge by crossing them, dangerous as the journeys usually are and uncertain as to the welcome – or lack thereof – that awaits them. The welcome given to Ukrainian refugees in Greece contrasts with the appalling conditions in camps “housing” Afghan refugees on the island of Lesbos (Markham 2022).

A key theme in contemporary social science is that of “mobilities”. This is a vibrant multidisciplinary field that deals with the geographical mobility of humans, nonhumans and objects, as well as information, visual images and, crucially, capital (Sheller 2015). It reflects more than the mere act of movement or transport, looking also at the emotional work that goes into this as well as the physical infrastructure necessary to enable movement. A related concept is that of “motility” – the potential to move – which “captures the unequal distribution of power over mobility, mobility resources and access to space” (Stjernborg, Wretstrand & Tesfahuney 2015: 384).

Brown and Taylor (2018) suggest that the study of health inequalities needs to be at the centre of geographical research on global health. It is therefore appropriate to begin an exploration of global health by describing, and explaining, the health inequality (more accurately, health inequity) that exists between and within different countries. “Health inequality” is invariably the term in common use, and so I follow that trend, although “health inequity” conveys more clearly that differences in health may be preventable – avoidable and unjust. The issue of who or what are responsible for avoidance – human agency, or wider structures of economy and politics – is still debated, although a critical geographical perspective suggests very much the latter. On this and other issues relating to health inequalities, the paper by Arcaya, Arcaya and Subramanian (2015) is valuable.

There is a vast literature on health inequalities in countries of the Global North, to which geographers have made key contributions, such as in the United States (McLafferty, Wang & Butler 2011), Canada (Shantz & Elliott 2021), the United Kingdom (Bambra 2016; Dorling 2013), New Zealand (Pearce, Tisch & Barnett 2008) and elsewhere. I do not intend to review these contributions, preferring to focus attention on some countries of the Global South. However, within some countries of the Global North there are marginalized groups to which I do want to give attention; in particular, as we see later, there are Indigenous populations occupying places that are as neglected as those who inhabit them.

The Global North literature on health inequalities tends to focus both on regional inequalities and, frequently, on more local – neighbourhood – variations. A classic distinction in this literature is between compositional and contextual effects (Gatrell & Elliott 2015: 82; Brown et al. 2018: ch. 8). In other words, is poor health in specific settings determined by the fact that poor people, with health-damaging behaviours, live there (the “composition” of a place) or by the fact that people live in places (“contexts”) that are environmentally or socio-economically deprived?

Geographies of health

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

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