Progress report

Progress in Human Geography

2014, Vol. 38(3) 466–475
Health geography I: ª The Author(s) 2013
Reprints and permission:

Social justice, idealist theory, sagepub.co.uk/journalsPermissions.nav

DOI: 10.1177/0309132513498339
phg.sagepub.com
health and health care

Mark Rosenberg
Queen’s University, Canada

Abstract
Health geographers have generally been content to adopt measures of distance, access and the lack of
resources as the metrics of social (in)justice without critically placing their research in a framework of social
justice. The purpose of this review is twofold: first, to examine recent research in health geography under
three themes – access to care, neighbourhoods, and health and environmental justice; second, to introduce
a debate about idealist theory as a way of introducing a theory of social justice into health geography which
might prove valuable to underpin what many health geographers are trying to do in their research on access
to care, neighbourhoods, and health and environmental justice.

Keywords
access, environmental justice, health, health care, idealist theory, neighbourhoods, social justice

I Introduction their way into the published research either in

the medical or health geography literature. In
While it is arguable about when social justice
fact, during this period, one might say that to a
entered the lexicon of human geography, many
large extent social justice in medical and health
would likely agree that the debates about what
geography was reduced to a simple formula:
social justice means and how to incorporate it
individuals and groups who had no or poor
into human geography began with David Har-
access to health resources or lived near toxic
vey’s (1973) iconic book, Social Justice and the
environments were assumed to be treated
City, and perhaps followed by David Smith’s
unjustly in their communities and their societ-
(1977) alternative arguments for social justice
ies; and a corollary of this formula was that indi-
following what he termed a ‘welfare approach’.
viduals and groups tended to be from those parts
At the time, medical geography was dominated
of the population who were already margina-
by approaches from cultural ecology and
lized because of their socio-economic status,
descriptive empiricism (e.g. see Meade et al.,
their ethnic or racial identities, gender, or some
1988). While there were a few exceptions (e.g.
Scarpaci, 1989), by and large, medical geogra-
phers were slow to embrace the social justice
debates up to the early 1990s. Even after Kearns
Corresponding author:
(1993) called for medical geographers to create Mark Rosenberg, Department of Geography, Queen’s
a more theoretically informed subdiscipline, University, Kingston, Ontario, K7L 3N6, Canada.
explicit theories of social justice rarely found Email: mark.rosenberg@queensu.ca
Rosenberg
combination of these characteristics and
identities.
It is not my intent to trace how and why med-
ical and health geographers have been reluctant
to embrace explicit theories of social justice.
Nor perhaps more accurately to explain why
they have been content to adopt measures of
distance, access and the lack of resources as the
metrics of social (in)justice without critically
placing their research in a framework of social
justice. Instead, the purpose of this review is
twofold: first, to examine recent research in
health geography under three themes – access
to care, neighbourhoods, and health and envi-
ronmental justice; second, to introduce a debate
about idealist theory as a way of introducing a
theory of social justice into health geography
which might prove valuable to underpin what
many health geographers are trying to do in
their research on access to care, neighbour-
hoods, and health and environmental justice.1
II Access to care
Access to care was one of the earliest themes in
health geography and remains a core issue for
study. There are, however, many differences
in what services are being studied, the ‘target’
populations and the methods now being used.
In early work, the studies mainly focused on the
geographical distribution of physicians and hos-
pitals. Populations were undifferentiated and
the main method of ‘explanation’ was ecologi-
cal modelling. Today, it is rare to find studies
of access to primary health care (general practi-
tioners or family physicians) or hospitals. The
few recent studies found where the sole focus
is on primary health care came from Canada
(Bell et al., 2013; Bissonette et al., 2012; Har-
rington et al., 2012), Ireland (Nolan and Smith,
2012), Jordan (Hundt et al., 2012), Rwanda
(Munoz and Källstål, 2012), and the United
States (Ryvicker et al., 2012). What is perhaps
more surprising is that, with so much emphasis
on the neoliberal state and the economic crisis
467
of 2008, one might have expected a new gener-
ation of research on restructuring of hospital
systems, hospital closures and declining access.
In this vein, Benning and Dellaert (2013) exam-
ine whether people are willing to pay more to
gain access to hospital services in the context
of a public health care system. In the mixed,
public-private system of Indonesia, Meliala
et al. (2013) find that specialists spend most of
their time practising at private locations and
only a small proportion of their time practising
in the public hospitals. There has also been
a small set of studies that focus on what might
be called the health service environment (access
to primary care, hospitals, etc.). Included in this
group of studies are Hine and Kamruzzaman
(2012), Shinjo and Aramaki (2012), Watanabe
and Hashimoto (2012), Cookson et al. (2012),
Blanford et al. (2012) and Comber et al.
(2011). One of the main emphases of this group
of studies has been to connect access to the
health service environment into large data sets
on travel behaviour, seeking to determine
whether people are making longer or shorter
trips by different transport modes (private car,
public transportation, cycling, walking) to acc-
ess health services and whether these patterns
differ depending on where people live and/or
over time, sometimes mediated by the socio-
economic characteristics of the people and/or
the places where they live.
What appear to be more common in the liter-
ature are studies that focus on health services
other than access to primary health care or hos-
pitals. On the one hand, the variety of services
examined is really quite impressive. There have
been recent studies on hospices (Gatrell and
Wood, 2012), harm reduction sites for intrave-
nous drug users (Cooper et al., 2012; Parker
et al., 2012), complementary and alternative
medicine sites (Meyer, 2012), cancer care (Wan
et al., 2012), gestational diabetes mellitus
screening (Cullinan et al., 2012), blood dona-
tion services (Cimaroli et al., 2012), paediatric
care (Heath et al., 2012), dental services (Chi
468
and Leroux, 2012), mental health services (Din-
widdie et al., 2013), specialist services for per-
sons with hepatitis C infections (Astell-Burt
et al., 2012), tuberculosis treatment (Huffman
et al., 2012), residential care for older persons
(Cheng et al., 2012), maternal care (Pilkington
et al., 2012), and hemodialysis (Salgado et al.,
2011). Like previous studies on access, once
one takes into account the particular service, the
focus of many if not all of these studies is on
the socio-economic characteristics of the users,
and then on the barriers that they face in acces-
sing services, particularly issues of distance and
the geographical configuration of where the ser-
vices are located.
A third set of studies has been spawned by the
food–physical activity–obesity nexus. To say
that there has been an explosion in the volume
of research on this topic in health geography and
more generally in health studies would be a
gross understatement. For the purposes of this
discussion, the focus is only on recent studies
of access to healthy food outlets (Caspi et al.,
2012; Jennings et al., 2012, Sadler et al.,
2011), recreational facilities and programmes
(Blacksher and Lovasi, 2012; Dahmann et al.,
2010) and parks (Cohen et al., 2012; Zhang
et al., 2011). In contrast to the studies of access
to health services, where the implication is that
access to a particular service has a direct effect
on one’s health, the implication of these studies
and many similar ones is that access to healthy
food outlets, recreational facilities and pro-
grammes, and parks only indirectly leads to
better health assuming one actually buys and
consumes healthy foods or regularly uses
recreational programmes and parks to improve
one’s health.
III Neighbourhoods
Closely related to studies on access, but seen
from an alternative perspective, has been a
focus on neighbourhoods, the characteristics
of the populations who live in them, the poor
Progress in Human Geography 38(3)
health of those who live in deprived neighbour-
hoods, and the lack of health and other services
available to them. Much of the research follows
one of three methodological paths. The first
path is to use a measure of health as an outcome
variable and individual or area-level measures
as the explanatory variables (e.g. Hale et al.,
2013; Hudson and Soskolne, 2012; McDonald
et al., 2012; Wen and Kowaleski-Jones, 2012)
to show the relative importance of area-level
measures which characterize relatively dep-
rived neighbourhoods possessing a higher like-
lihood of relatively more people living in poor
health. A second and now increasingly routine
path in these studies is to develop or use an
already developed index of relative material,
social or combined deprivation to demonstrate
that those people living in neighbourhoods with
high levels of deprivation are more likely to
have poor health outcomes (e.g. Ellaway et al.,
2012). What has changed in this literature is the
increasing focus on specific groups (e.g. Flouri
et al., 2013; Poeran et al., 2013; Puett et al.,
2012), specific health outcomes (e.g. Chaikiat
et al., 2012; Mair et al., 2012; Reitzel et al.,
2012) or specific services in the neighbour-
hoods that are health-promoting (e.g. Black
et al., 2012). The third path has been to look for
new ways to characterize deprived neighbour-
hoods. For example, Bellis et al. (2012) use clus-
tering techniques addressing a much broader
range of neighbourhood characteristics across
30 health and social measures to classify United
Kingdom local authorities into five types, while
Richardson et al. (2013) develop an environ-
mental index which includes air pollution, noise
pollution, the traffic environment, undesirable
land uses and health inequalities in their study
of health inequalities among Scottish neigh-
bourhoods. Shortt et al. (2012) apply a similar
environmental approach in a study in New
Zealand.
In a sense, neighbourhoods have become
a methodological battleground among health
geographers, with research reflecting spirited
Rosenberg
debates mainly about: what constitutes a neigh-
bourhood (i.e. are neighbourhoods defined
socially, administratively, etc.); what features
define ‘good’ (e.g. green and blue spaces, places
to buy healthy food at affordable prices, etc.)
and ‘bad’ (e.g. abandoned buildings, lack of
public services, etc.) neighbourhoods and for
whom; or whether individual factors or area fac-
tors are relatively more important in ‘explain-
ing’ poor health, access to health services or
health-promoting services. The papers cited
above speak to the progress made methodologi-
cally in what roles neighbourhoods might play
in improving health, access to health services
or health-promoting activities, but what is miss-
ing are commensurate debates about underlying
theory, especially at a time when all levels of
government in many places are looking for
ways to reduce the role of the state through
service cutbacks and less support for the people
who live in the neighbourhoods where the
research is being carried out.
IV Health and environmental
justice
In many respects, the environmental justice lit-
erature echoes methodologically the accessibil-
ity and neighbourhood literature. Whereas the
accessibility literature implies that living closer
to health care resources means better access to
health care and, by inference, better health out-
comes, the environmental justice literature
implies that living closer to sources of environ-
mental pollution means a higher likelihood of
contamination and, by inference, poorer health
outcomes (e.g. Amram et al., 2011; Jephcote
and Chen, 2013; Saha et al., 2011; Viel et al.,
2011). Similar to the neighbourhood studies
described above, a key issue in the environmen-
tal justice literature is determining how much of
the health outcome can be attributed to individ-
ual and/or area socio-economic characteristics
and health behaviours, and how much can be
attributed to the dose-response relationship of
469
the environmental hazard under study (e.g. Bra-
nis and Linhartova, 2012; Chen et al., 2013;
Collins et al., 2011; Grineski et al., 2013; Hipp
and Lakon, 2010; Kershaw et al., 2013).
The health and environmental justice litera-
ture, however, differs from the accessibility and
neighbourhood literature in one important way.
The environmental justice literature explicitly
invokes the concept of justice, even if what is
meant by justice is rarely discussed here beyond
the implicit arguments that living in proximity
to environmental hazards is unjust or that the
actions ensuring that environmental hazards are
more likely to be located in places nearest to
marginalized populations are unjust. Again,
what is often lacking is what does justice actu-
ally mean in the context of improving health,
especially when causality of health outcomes
can rarely be demonstrated and interventions
(e.g. cleaning up the sources of pollution or
moving people to other residential areas) are
beyond the resources of either the people living
in the neighbourhoods or local levels of govern-
ment to effect. Compounding the complexities
of these issues is whether such remedies – espe-
cially if they mean the closure of a facility –
might in fact mean the loss of much of the
economic vitality of the neighbourhoods in
question.
V Methodological advances
The studies above also reflect the current and
growing variety of quantitative, qualitative and
geographic information systems (GIS) methods
being used across human geography. Various
forms of multivariate regression modelling
(e.g. Dahmann et al., 2010), multi-level model-
ling (e.g. Cooper et al., 2012), logit modelling
(e.g. Cullinan et al., 2012) and logistic regres-
sion (e.g. Dinwiddie et al., 2013) remain the
most commonly used methods for the exami-
nation of access to care and environmental
justice. As governments increasingly invest in
regular (e.g. annual or biannual) cross-sectional
470
population health surveys or longitudinal sur-
veys, some researchers are beginning to tackle
the connections between spatial and temporal
change (e.g. Ellaway et al., 2012; Watanabe and
Hashimoto, 2012). While the increased use of
deprivation indexes internationally is a wel-
come trend, the development of an environmen-
tal index by Richardson et al. (2013; see also
Shortt et al., 2012) opens up two new directions
for consideration: one is to build on their
research to improve the index which they have
demonstrated has applicability in two different
national settings; and the second is to consider
whether new indexes of the health service envi-
ronment and the built environment might be
advantageous in research on access to care or
parks and recreational services, respectively.
The integration of data sets (sometimes referred
to as small area data analysis or data linkage)
holds great promise in the three areas of
research already discussed, but also raises some
complex ethical questions around confidential-
ity and privacy (e.g. Blacksher and Lovasi,
2012). In the GIS community, there has been
growing interest in applying the Two Step
Floating Catchment Area method (2SFCA) and
improvements upon it (e.g. Harrington et al.,
2012; Luo and Whippo, 2012; Wan et al.,
2012). With only a few exceptions (e.g. Heath
et al., 2012; King et al., 2009; Parker et al.,
2012), what remains missing across the three
themes is qualitative research to provide a
deeper understanding of what the lack of access
to care or living adjacent to toxic sites or con-
stantly exposed to toxins means to people in
their everyday lives.
VI Social justice and the idealist
versus non-idealist theory debate
Almost without exception, the research
reviewed above, and indeed much of the past
research, which has focused on access to care,
neighbourhoods and environmental justice,
stems from a position of social justice. The
Progress in Human Geography 38(3)
research implies that it is unjust that some peo-
ple are denied access to care because of: where
they live; who they are; the absence of services
in their neighbourhoods; or the presence nearby
of sources of pollution. Implied in the research
is that any improvements (e.g. eliminating dis-
criminatory barriers to access to care) directly
or indirectly must lead to improvements in
health, and therefore the unspoken if plausible
assumption is that any such improvements are
more socially just. The dilemma is that rarely
is the research grounded in an explicit theory
of social justice, although various conceptual
frameworks are sometimes cited as guiding the
research (e.g. ‘the social determinants of health’
framework). For example, in the absence of all
economic, social and cultural barriers to access
to care, some people will still remain geographi-
cally farther away from services than others.
Similarly, in the absence of the elimination of
all socio-economic differences in a population
and obvious variations in the built environment,
deprivation indices will always reveal that some
people live in relatively deprived areas com-
pared to others. Or, in the absence of the elimi-
nation of all pollution, some people will always
live nearer to sources of pollution than others.
Taking such absolute positions as socially
unjust, however, does not necessarily lead to
social justice if, for example, the elimination
of all pollution also means that an economy is
impoverished because there is no economic
activity to sustain it. In other words, how should
one position access to care, neighbourhood or
environmental justice research within a theory
of social justice?
While there are various possible political phi-
losophies that could be adopted to resolve this
dilemma, one possibility that has not received
much attention and might prove particularly
useful in health geography is to consider ‘ideal’
and ‘non-ideal’ theory (Valentini, 2012).
Following Valentini, ideal versus non-ideal the-
ory has its roots in the work of Rawls (1999) and
has spawned an increasingly complex debate
Rosenberg
around three themes: ‘full compliance’ theory
versus ‘partial compliance’ theory; ‘utopian or
idealistic’ theory versus ‘realistic theory’; and
‘end-state’ theory versus ‘transitional’ theory.
Briefly, compliance theory versus partial com-
pliance theory is a debate about what ‘duties and
obligations apply’ to the individual ‘in situa-
tions of partial compliance as opposed to situa-
tions of full compliance’ (Valentini, 2012: 654).
Utopian or idealistic theory versus realistic
theory is a debate about ‘whether feasibility
considerations should constrain normative
political theorizing and, if so, what sorts of fea-
sibility constraints should matter’; and end-state
theory versus transitional theory is a debate
about ‘whether a normative political theory
should aim at identifying an ideal of societal
perfection, or whether it should focus on
transitional improvements without necessarily
determining what the ‘optimum’ is’ (p. 654).
Table 1 summarizes the overall grid of theoreti-
cal possibilities here.
In the context of full compliance theory
versus partial compliance theory and accessing
primary health care, one might consider the dif-
ferences between ensuring that everyone has
access to as much health care as they need (full
compliance), set in contrast to ensuring that
everyone has access to some primary health care
over a specified time and geographical space,
but acknowledging that no health care system
can provide all of the care that a person needs
and that some people will always choose (or
be constrained) to live in places where they have
less access to care or live in places farther away
from care no matter what the geographical dis-
tribution of care might be (partial compliance).
Utopian or idealistic theory might define a
socially just health care system such that there
are no barriers to health care at any level of
service (primary, secondary, tertiary, etc.),
for any type of service (physician, nursing,
home care, etc.) or any ancillary needs (pre-
scriptions, wheelchairs, etc.), covering all of
the population through general government
471
Table 1. Summarizing idealist versus non-idealist
theory (after Valentini, 2012).
Idealist theory Non-idealist theory
Full compliance theory Partial compliance theory
Utopian or idealistic Realistic theory
theory
End-state theory Transitional theory
revenues. Applying realistic theory, the starting
point for research on access to health care might
be what can a society feasibly provide in a
socially just fashion within the constraints of
what funds actually exist for its health care sys-
tem. End-state theory applied to access to health
care might be about defining a health care sys-
tem which achieves access in a socially just
fashion. It is distinct from a utopian or idealistic
health care system in that the end state might be
a health care system that guarantees no one is
more than a specified distance from a primary
health care provider. In contrast, taking a transi-
tional theory position would suggest that, even
if one cannot define the end state, any improve-
ments to access to primary health care which
removes any barrier (economic, sociocultural
or geographical) are worth making because they
move a society closer to a socially just system,
even if one cannot specify what a socially just
system might ultimately be.
Conclusions
We live in a time when governments in many
parts of the world, both developed and develop-
ing, are restructuring or withdrawing health care
and social support services and/or are creating
greater inequities through their tax policies, cuts
to transfer payments to the most vulnerable, or
policies that create more unemployment. The
research reviewed above plays an important role
in exposing who, in terms of their socio-
economic and demographic characteristics and
where they live, are most affected by either
overt action or the lack of action, which directly
472
or indirectly affects human health and, ulti-
mately, exposes the lack of social justice in our
communities.
Some health geographers might be inclined
to take comfort in adopting an idealist position.
Many health geographers are, however, grap-
pling with the ‘messy’ realities of geographies
of access to care, neighbourhoods lacking in
infrastructure or located proximate to polluted
sites, and, most importantly, populations mar-
ginalized by their gender, race and/or ethnicity.
If we are to pursue theories of social justice in
health geography, non-idealist theories might
provide directions for anchoring our research
in meaningful ways that can lead to changes and
improvements in people’s health even at a time
of cutbacks and declining state involvement.
Using the debate about idealist versus non-
idealist theory opens up various ways of
theorizing about how social justice might be
incorporated into research in health geography.
Beyond the various positions taken in this
debate, there are indeed other possible ways of
theorizing social justice which might also be
considered for advancing research in health
geography. If health geography is to continue
to advance, though, theory development needs
to catch up with developments in methodology
in moving from critical examination to action
in the study of access to care, neighbourhoods
and environmental justice.
Acknowledgements
I would like to thank Kathi Wilson and Chris Philo
for their support and suggestions on earlier drafts
of this paper.
Note
1. In the remainder of the paper, I only refer to health geo-
graphers and health geography as the more inclusive
terms, although I acknowledge there are still some geo-
graphers who see themselves as medical geographers or
continue to use the term medical geography as distinct
from health geography. It would only be misleading to
use the term health geography when referencing work
prior to the 1990s when those doing research on health
Progress in Human Geography 38(3)
and health care referred to themselves as medical geo-
graphers and their research as medical geography.
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