Health geographies III – Landscapes of care

In this third report, I focus on the concept of ‘landscapes of care’ in health geography. I explore three interrelated areas of recent work: landscapes of inequities and slow violence; landscapes of care as more than clinical, and more expansive ways to think about landscapes of care. All raise interesting questions about defining and understanding different kinds of care, complexities of familiar and new landscapes, the transformative potential of care, and the fraught and non-innocent politics of care. I argue that we still need to pay more attention to interdependence and experiences of receiving as well as giving care.


I Introduction
Landscapes of care encompass macro and local arrangements and flows of care and caring interactions, and the relationships between them.Caring is a situated and relational practice and experience.The macro factors that shape and reshape the provision and distribution of resources and services for health connect to both particular and generalized geographies of paid and unpaid, human and non-human individuals and groups who give and receive care.At the local, regional, or even international scale, place impacts on, and is shaped by, the distribution, availability, flows, and composition of health and social care policies, practices, workforces, and agents over time.Landscapes of care also include the variety of institutional, domestic, familial and community, national and international scales at which care is provided and received; the full gamut of public, private, third sector, and combined funding and spaces for care; professional, paid, unpaid, and voluntary provision of care; and the spatial and temporal transitions within and between all of these (Milligan and Wiles, 2010).
Similarly useful metaphors include topologies of care (Hanrahan and Smith, 2020), ecological frameworks of care (Bowlby and McKie, 2018), and at a smaller scale, care convoys or situated networks of care (Kemp et al., 2013).The idea of landscapes of care builds on and connects work on therapeutic landscapes with its emphasis on the interconnectedness of material, social and symbolic (Kearns and Milligan, 2020), and work on access to and experiences of care.All these frameworks are useful to capture the interaction of resources, processes, ideas, and place in the provision and experience of care, putting care firmly in place.They also emphasize how care often 'ripples out into the world' (Hanrahan and Smith, 2020) so that wider social, cultural, environmental, economic and political as well as personal contexts both shape and are shaped by care, in ways that are both positive and problematic.This raises interesting questions, for example, about how we identify and define landscapes of care, and how they interact across contexts and scales, from bodies to global interactions?How do we understand different kinds of care practices, in and between environments and settings that are more and less institutionalized, regulated, and resourced?How do we account for and measure different kinds of care, or understand the complexities of interdependence of care, and the experiences of giving and receiving care?How are places transformed by care, and how is care produced and enabled by place?How do we understand the fraught politics of care and especially, how do we explore the ways that care is not always neutral, innocent, or beneficent?
In this third report, I explore recent health geography work that has expanded this framework of landscapes of care to address such questions.I argue that as a framework landscapes of care helps to understand and shape politically more 'fair' landscapes of care, through (1) conceptualizing spatial inequities and injustices in care, which both cause and are the outcome of 'slow violence', (2) illuminating how landscapes of care are much more-thanclinical, and (3) supporting new ways to understand landscapes of care, including the transformative potential that could contribute to hopeful adaptation in the context of adversity (Power et al., 2019).

Inequities and slow violence in accreted landscapes of care
Consistent with the core tenets of health geography, work on landscapes of care continues to identify classic spatial patterns of inequity of distribution of care resources across and within landscapes.Community-based care resources are unevenly distributed at the local level, because of political interactions at much larger scales of time and space, exacerbating long-standing inequities for the disadvantaged communities that would benefit most from better integrated and distributed care (Bell et al., 2021;Fishman et al., 2018;Winata and McLafferty, 2021).These inequities accumulate across spatial and temporal scales, as shown by work such as Phillips II et al.'s (2023) geospatial exploration of how historical and contemporary racism shape the current availability of neighbourhood resources to promote more equitable uptake of Preexposure Prophylaxis (PrEP) in Chicago.Nixon (2011) concept of slow violence, developed in the context of understanding how communities coping with poverty experience climate change, deforestation, and the environmental aftermath of war, is highly pertinent to these situated inequities within landscapes of care.Work on slow violence focuses on incremental, 'invisible', accretive violence and staggered harm, with repercussions playing out across a range of temporal scales (Nixon, 2011).Political geographers Pain and Cahill (2022) draw-out the spatialities of slow violence, foregrounding critical feminist and anti-racist perspectives, and prioritizing the accounts of those who experience and are most affected by slow violence (which, as they argue, is only 'invisible' depending on where the gaze is centred).Meshing these concepts with the landscapes of care framework further sharpens our understanding of care as contested process.They emphasize how causes and implications of inequities in care and access to resources for care are not just 'in the present', or at the local level, but embedded in multi-scale, multi-sited political, temporalized processes and places (Bambra et al., 2019).It is also helpful to consider how the accretion of injustices in landscapes of care entwines with the accretion and build-up of hopeful, enabling places and resources and spaces for care (Andrews, 2017).For example, Rishworth & King's qualitatively informed consideration of new HIV management regimes in South Africa unpacks intersections of place, identity, and climate change and socio-ecological systems in shaping both hopeful and uncertain new experiences (King et al., 2023;Rishworth and King, 2023).
Urban health researchers have observed how the Covid-19 pandemic made the accretion of urban health inequalities and privileges starkly more visible (Cole et al., 2021), disproportionately impacting on specific groups and places (Buffel et al., 2021;Power and Herron, 2021), and exacerbating inequities for deprived areas and places already affected by cuts to public services, loss of social infrastructure, and pressures on voluntary sectors (McLafferty et al., 2021).Contemporary and historical discrimination in mutually reinforcing systems (housing, education, employment, benefits, and media) at multiple scales contributed to inequities in COVID-19 exposure, morbidity, and mortality, with minoritized groups and neighbourhoods of lower socio-economic status hit especially hard (Berkowitz et al., 2021).
Expanding our thinking to urban and regional scales offers productive ways to think about landscapes of care, the flows of processes, and accretion of resources and gaps.Power and Williams' (2019) call for broadening conceptualizations of care in geographical research to be more inclusive of urban governance, planning, and management.This encompasses work such as Wray et al.'s (2021) research on local government decisions to invest in green and blue spaces and active transport infrastructure or in infrastructure for cars.They show how these shape long-term outcomes for cities, with those investing in public and active spaces able to be more caring instead of punitive in the context of future public health and climate-related emergencies like Covid-19.Urban design and land-use policies can also contribute to creating everyday built environments that are caring or care-less, as illustrated by Biglieri and Dean's (2021) work on walking in suburban neighbourhoods for people living with dementia and their experiences of negotiating traffic density, median strips, or buffer zones and crossings.Similarly, Hartt et al.'s (2021) edited book focuses on how places shape older adults' wellbeing, exploring how local community built and social environments can be the difference between enabling or disabling housing, transportation, cultural safety, employment, health, and planning for both older individuals and communities.In a thoughtful examination of the nonneutral potential of care practices in urban redevelopment, Ruming and Zurita (2020) show how caring acts from individual relocation officers (like offering support or sharing food) un/consciously facilitate the more efficient relocation and dispossession of the disadvantaged tenants, ultimately benefiting private and neoliberal government interests.
Research on the inter-scalarity of landscapes of care in the context of decentralization and austerity leads to observation of new spatializations and contradictions in urban care and associated planning and decision-making.For example, Swedish researchers have explored how efforts to move psychiatric mental health care away from large institutional buildings to other kinds of care (like community clinics, home-based care, supported living, or financial allowances) are leading to 'new urban frontiers' for care, highlighting the often unintended outcomes of decisions and efforts by both planners and service providers (Fjellfeldt et al., 2021;Högström, 2018;Markström et al., 2023).Macpherson et al. (2023) similarly highlight the instability and fragmentation of landscapes of care and support for people with learning disabilities in the context of restructuring and austerity England and Scotland.
Contributors to the book Care and the City (Gabauer et al., 2022) examine other ways in which caring and uncaring practices intersect and are embedded in urban social spaces.For example, one chapter frames stories of childbirth in Australasia to illustrate a theory of community economy, shared interdependence, and infrastructures of collective care (McKinnon et al., 2022); another investigates how certification of LGBT-friendly eldercare in the Netherlands is reshaping socio-spatial inequities in care across cities in the Netherlands (Pijpers, 2022); while another unpacks struggles over the broadening roles of Toronto and other public libraries as urban sites of care, social repair, and maintenance (Abbruzzese and Riley, 2022).Rural work also draws on the complex flows and interactions within landscapes of care.For example, Sangaramoorthy (2023) explores how connections between the corporatization of health care and immigration create precarious landscapes of care with shared conditions of inequities and anxiety for migrants and rural residents in rural Maryland USA.Poulin et al.'s (2023) analysis of older adult care transitions through rural health systems examines tensions between macro efforts to make the system of admission and discharge efficient and the care against the experiences and aspirations of individual older adults, emphasizing the need to attend to population health and individualized health.
2 More-than-clinical: What else happens here?
In addition to expanding our understanding of landscapes, we are increasingly expanding our ideas and understanding of care itself, pushing past either a clinical focus or treating place as simply setting or container for care to understand the multifaceted ways we maintain, continue, and repair our worlds.Often this work includes a focus on power and contestation, and different interpretations and experiences of care, and highlights more-than-clinical and more-than-therapeutic experiences and interactions (Emmerson, 2019).
For example, Kearns et al. (2020) consider the reception or waiting area in primary health care settings, observing how these can be very confronting spaces for those who already experience various forms of social marginalization but could be more enabling if they were more permeable, for example, allowing people to wait outside (Neuwelt and Kearns, 2021).Duncan et al. (2021) use longterm participatory ethnography to map spatial and affective assemblages of care and power relations in a drug consumption room in Germany, such as whether spaces create a sense of warmth and acceptance, where staff 'sit' in relation to clients, or how 'looking' happens, how trust and belonging are built; and also more negative aspects such as staff experiencing their own sense of futility, frustration, and despair in their roles.Giesbrecht et al. (2018) similarly explore how power relations expressed and enabled though the characteristics of formal care settings shape experiences of and access to palliative care, reinforcing structural vulnerability and inequities in access to care for people who are homeless or struggle with substances.Olding et al.'s (2023) ethnographic study of overdose prevention clinics in Vancouver shows how sites have multiple meanings and uses for different users, some of whom see these as sites as also being for mutual aid, sheltering, or income generation through selling drugs, leading to conflicts and sometimes unintended outcomes when care providers try to prioritize how such spaces should be used.Ivanova et al. (2020) considered case study of an illegal baby foundling room in the Netherlands, where one may abandon one's infant anonymously, extends these ideas about the complex relationships between care and place or 'placed care', and the politically delicate ways these operate from the level of individual emotions to governmental practices.All of this work on place-based interventions for harm reduction is valuable, not only for their attempts to unsettle depictions of care as innate, but also their efforts to trouble and to critically engage with care's 'fraught politics' and the 'noninnocent' potentials that enable or constrain different landscapes of care (Duncan et al., 2021: 628-629).
In their pre-Covid visual and ethnographic research on spatially oriented practices and ethics of care in a cystic fibrosis clinic, Buse et al. (2020) show how clients regarded clinical staff practices of social distancing as careful, and actively participated in an ethic of care themselves by maintaining a space between bodies in communal areas, and 'holding back' and 'looking out' in confined spaces, although segregation sat at odds with some clients' desire to socialize and connect.In later work they show how this careful choreography of material environments and bodies helps to understand the role of materialities, mobilities, and design of care settings in the construction of risk, which is highly relevant post-COVID pandemic (Martin et al., 2023).Relatedly, Harrison et al.'s (2023) post-COVID work on the 'fluid hospital' focuses on the material and affective movements and flows that organize the hospital, showing how hospitals have unfixed, permeable boundaries.By framing their work at the level of care landscapes, their research highlights how care providers could reorganize routines and spaces of care with evolving potentials, with some of the adaptations, new skills, and technologies deployed during the pandemic having applications for future hospital care.
Beyond clinics, health geographers have investigated the role of other, local, community-scale landscapes of care.This includes 'third places', many of which are under increasing threat of closure or change (Finlay et al., 2019;Power and Hall, 2018).Morse and Munro (2018) position museum community engagement services as part of wider landscapes of care, framing their caring practices (such as welcoming and including participation of vulnerable excluded individuals, or making visible local partnerships and celebrating local front-line services' achievements) as enabling resistance and undermining austerity.Research on efforts to support and upskill library workers and co-locate social workers in libraries is another example of innovative beyond-clinical third spaces within landscapes of care (Garner et al., 2021).Slocombe's (2023) work on older people's experiences within food banks highlights how food banks are not just transactional spaces for handing over food but also function as vital social spaces, creating opportunities to talk and connect over a cup of tea, in spite of generational dynamics of shame and stigma associated with such spaces.In examples of innovative landscapes of care, Smith et al. (2021) identify benefits of live music in a purposely designed music café for communitydwelling people living with dementia (PLWD) and their care partners, while Mmako et al. (2020) highlight the positive impacts of engagement with green spaces including urban woodlands, parks, and green care farms for PLWD.And in an example of reframing our understanding of familiar places for care, Holland (2022) unpacks the invisible and complex health work of negotiating place-based factors and the interaction of care and the care environment for unpaid family caregivers in rural Canada.
Some health geography work focuses on the importance of encouraging agency in landscapes of care for specific population groups.For example, Veronese et al. (2020), drawing on work with children in a Palestinian refugee camp, argue that supportive interventions should promote children's spatial agency and participation in transforming spaces for their own protection and to improve community wellbeing.In their study of refugee and migrant adolescents' experiences in Danish schools, Borsch et al. (2021) similarly emphasize the need to consider students' own ways of caring and active contributions, as well as the structural pressures and responsibilities they are subject to.

Expanding understandings of landscapes of care
Care is a topic of increasing interest to a wide range of geographers and other scholars.Hanrahan and Smith's (2020) special collection in Area reimagines the diverse and shifting production of care relations and practices as topographies of care, focusing on the spaces in-between subjects, and the navigation of disconnections during receiving and giving care (Hanrahan, 2020).Lin et al. (2022) outline a research agenda for cultural landscapes of care in a special issue of Health & Place, committed to contextually sensitive understandings how culture filters through diverse everyday care practices.A central part of this research agenda is thinking through connections between institutional understandings of responsibilities of care and more fragmented forms of care within different careful geographies.In a collated issue of Social & Cultural Geography (Greenhough et al., 2023), researchers explore what it means to think about and practice care across different settings, political contexts, and scales, whether institutional, political, human and non-human, local or regional, temporal, and particularly to think of culture with care.They include an expanded focus for care, including entities such as soils or non-human animals, as well as the capacity to care as generated in material, governance, and discursive infrastructures of care (Power, 2019).
This work on cultural landscapes of care has opened exciting possibilities and the potential for increased theorization both of care itself (Wiles et al., 2018) and the interactions of places and care.For example, Chen et al. (2022) explore how care for people with intellectual disabilities in institutionalized spaces is framed and enacted through various culture-specific paradigms that while attentive and respectful, are also paradoxically disabling (such as the charity paradigm or fictive kinships of Confucian care).In a good example of how care can be simultaneously immediately proximate and distal (Milligan and Wiles, 2010), Ivanova (2022) employs ethnographic work with Bulgarian temporary migrant carers working in Italy who 'care in less-thancaring landscapes' to understand the complex ways they make sense of their roles and their caring practices, both as mothers who are physically distanced from their children so as to provide resources for them, and as paid carers to individual older people in a globally situated market for care.Yu and Rosenberg (2022) likewise interrogate assumptions about individual choice and independence in ageing in place, arguing these are often unhelpful in other cultural contexts.They demonstrate how grounding an understanding of care in geo-historical contexts (for example,-pre-reform Collectivism and socialist ideologies in China such as equality, standardization, and uniformity) creates new perspectives on flows of care and power in the broader frames of institutions, markets, and moralities in care, and how these connect to ways individual care workers and older people constantly renegotiate norms and boundaries of care along with their own identities and living conditions.Schwiter and Steiner (2020) draw on economic geographies to explore private households as precarious and feminized workplaces for paid migrant workers where care labour is devalued, and digital technologies have ambivalent effects on care.Chen et al. (2024) similarly explore the contradictory narratives of domestic landscapes in the smart-home industry, which promote gender equality while reinforcing gendered stereotypes of domestic care, highlighting how care can be at once transformative and yet also reinforcing of existing structures and power relations.
There is still room for more research both to conceptualize situated experiences, meanings, and enablers of care itself (Wiles et al., 2018), and most especially, on experiences and meanings of receiving care (Wiles, 2011).Work on intersections of culture and landscapes of care opens up scope to develop work that expands beyond national and ethnicity cultures to include considerations of other kinds of culture (such as professional cultures and ideas about care, or the intersection of norms and values and the material world in the context of different institutional and social settings (Chen et al., 2022).New resources and reimagined subjects and spaces for providing and receiving care are also usefully explored through landscapes of care while also expanding our understanding.For example, Gorman and Davies' (2023) work explores the social and ethical implications of incorporating animals within various caring and health-promoting practices, including patient involvement around animal research and what happens when different institutional cultures (biomedical research, people affected by health conditions) intersect.King (2023) offers a thoughtful reflection on how a culture of care might inform the relationship between university research ethics reviews and care as a continual practice of exchange with research participants or partners throughout research.Bartos' (2020) spatial relational care approach to understanding caring and noncaring practices in the context of campus sexual assault highlights the power of the gendered, legal structures that produce uncaring practices.Mahony's (2023) recent report in this journal reflects on the potential for care as an aspect of more responsible research practices, purposes, and products in science and technology.He highlights new relationships of mutuality and reciprocity with research participants, argues for the need for theoretical reflexivity and responsibility in physical geography and technoscience, while also raising questions of the noninnocent and commodification potentials of care.

Summary
Landscapes of care continue to furnish rich conceptual frameworks and new horizons for thinking about care, encouraging us to connect scales, times, politics, and places as we think about how we maintain and repair our worlds to live as well as possible.Landscapes of care help us to understand care in new spaces beyond homes and clinical care settings, in new kinds of juxtapositions and relationships, in new ways and with new subjects, and as both helpful and less-than-caring or non-innocent.For this conceptualization to continue to be relevant, it is important that we think carefully about landscapes, and the interactions, processes, flows, and accretions of physical and social and symbolic resources and experiences.It is also critical that we think carefully about defining what is (and is not) care itself.But most of all, we urgently need to think more about experiences and meanings of receiving care as well as giving care, and the ways that all of us are, to more or less visible extents, interdependent on care.

Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.