Strange Geography of Health Inequalities - Susan J. Smith and Donna Easterlow, The - Unknown

The Strange Geography of Health InequalitiesAuthor(s): Susan J. Smith and Donna EasterlowSource: Transactions of the Institute of British Geographers, New Series, Vol. 30, No. 2 (Jun.,2005), pp. 173-190Published by: Wiley on behalf of The Royal Geographical Society (with the Institute of BritishGeographers)Stable URL: http://www.jstor.org/stable/3804517 .

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The strange geography of health inequalities

Susan J Smith and Donna Easterlow

Place is undoubtedly relevant to health, and geography is a central character in the story of how rich societies handle inequalities in death and disease. But the text is incomplete, its scope limited by a too-delicate encounter between research and policy, and by a strange subdisciplinary divide. Accounts of the geography in health inequalities are largely, albeit subtly, locked into 'context'. They document the complex extent to which different (material, social and cultural) environments undermine or enhance resilience. They tell the tale of risky places. Our complementary narrative is written around the findings of qualitative 'compositional' research. It is about the way health itself is drawn into the structuring of society and space. This geography is a map of health discrimination, illustrated in the processes of selective placement, entrapment and displacement. By drawing attention to the 'healthism' of politics and policy in 'care-less' competition economies, this enlarged perspective might enhance the role of geography (and geographers) in both understanding and managing health inequalities.

key words Britain health inequalities health histories qualitative research policy relevance context and composition

Department of Geography, University of Durham, Durham DH1 3LE email: susanj.smith~durham.ac.uk

revised manuscript received 22 November 2004

Introduction In less than a decade, geographers' concerns with inequalities in health have changed rapidly and expanded enormously. A small, epidemiologically- orientated subdiscipline of medical geography has been eclipsed by a richer body of theoretical and empirical speculation concerned with disease prevention, health promotion, charting resilience and enhancing wellbeing. A new 'health geography' has been established (Kearns and Moon 2002; Pearce 2003), and there is scarcely any area of environmental, bio- or human geography which remains untouched by this shift.

Being well is the Holy Grail of all societies; life takes place under the lens of a 'healthist' gaze (Brown and Duncan 2002). As political projects, preventing illness and curing disease are central to governments' agendas, especially in the more eco- nomically developed world. Here, premature deaths

from undernutrition and infection are relatively low, life expectancies are long and quality of life attracts a premium. These are the 'healthy nations'. And yet, for some of the richest among them, including the UK and the USA, a major challenge is the discovery that, as incomes increase, wealth becomes more polarized (Alderson and Nielson 2002; Atkinson 2003). Both trends, moreover, are associated (in debatable ways) with an enduring and widening health divide (Lobmayer and Wilkinson 2000; Coburn 2004). It is not surprising that the vexed question of health inequalities has attracted so much attention in these societies, or that such inequalities have become so relevant to the 'policy turn' in research.

Geography is a central character in the story of how rich societies have monitored and managed their health divides. Yet the discipline's perform- ance elaborates a rather strange tale. The narrative is uneven and incomplete, with maybe half the text

Trans Inst Br Geogr NS 30 173-190 2005 ISSN 0020-2754 ? Royal Geographical Society (with The Institute of British Geographers) 2005



174 unwritten. This partiality is exposed in our opening discussion, which offers a critique of some dominant (academic and political) accounts of the links between space and health. We argue that the pre- valent paradigm - a tale of risky places - stems from a too-delicate delicate encounter between research and policy and a surprising inclination to 'subdis- ciplinism'. In the second part of the paper we draw from our own research to document a less obvious, if complementary, perspective on health inequality. This geography is a map of health discrimination. It is the product of selective placement, entrapment and displacement. These are socially structured and institutionalized processes which accumulate across the life course, subtly but systematically dif- ferentiating populations according to health histories and prospects. To illustrate this discussion, we turn the spotlight towards Britain: a country that is both rich and unequal, which led the world's experi- ments in monetarism in the 1980s, and spearheaded a 'U'-turn out of equality in the 1990s (Harrison and Bluestone 1988). Combining growing affluence, limited redistribution, increasing socio-economic disparities and a widening health divide, Britain aptly contextualizes this cautionary tale.

Strange geographies? That health inequalities have a geography is not at issue, although anyone reviewing the literature of the 1980s and early 1990s might be forgiven for overlooking this. In Britain, for example, the only geography in the influential Black report (Depart- ment of Health and Social Security 1980), which more or less defined the research agenda for over a decade, was that relating to the North-South divide. The health inequalities debate this inspired thus hinged primarily around the relative importance of (material and behavioural) factors whose influence might as well be manifest on the head of a pin as in the geometry of space. These factors have been subject to numerous critiques (e.g. Davey Smith et al. 1990; Macintyre 1997), and in recent years both government and university researchers have gone on to document large, and growing (though not uncon- troversial), disparities in premature deaths and chronic disease at a range of spatial scales (Secretary of State for Health 1998 1999; Shaw et al. 1998 2000; Griffiths and Fitzpatrick 2001). Geography clearly matters for health inequalities. The question is, how?

The answer is strange. For despite calls from within the discipline for a better conceptualization


and operationalization of the complex relation- ships between health, space and place (Kearns and Joseph 1993; Jones and Moon 1993; Kearns 1995; Tunstall et al. 2004), the geography in health inequalities has come to hinge almost exclusively around a set of mainly practical questions concerned with how much (and in what ways) place matters for health. Interestingly, the pace was set by medical sociologists, rather than geographers, notably in the impressive agenda pursued by the MRC Social and Public Health Sciences Unit and the Department of Housing and Urban Research, at Glasgow University. In an extraordinary series of articles, these scholars pieced together the full range of local social and physical environmental features likely to have health effects. They highlight the uneven distribution of health-relevant features across small areas and show how this is reflected in residents' health profiles and beliefs (see Macintyre et al. 1993 1997 2002 2004; Sooman and Macintyre 1995; Ellaway and Macintyre 1998; Macintyre and Ellaway 1998; Ellaway et al. 2001). This amounts to a substantial platform from which to argue for the effects of place - or context - on health. Where people live matters because there is a geography of physical and biological health risks, and of therapeutic landscapes. Differential exposure to risks and unequal access to health- promoting environments underpins the spatial health divide.

There is a sense in which this amounts to a rather conventional, even mildly outdated geography (how environments affect health ... ). However, it is worth noting that there was at the outset a radical edge to this approach. Macintyre et al., for example, issued a political as well as a scholarly challenge in advocating

research which focusses directly on the health- promoting or health threatening features of local social and physical environments, and local and national health promotion policies which take account of the features of places as well as features of people. (1993, 232)

This perspective assigns responsibility to governments and collectivities rather than individuals for maintaining public health. After a period of neo- conservatism in which 'health variations' were accounted for politically with reference to personal lifestyles and individual behaviours, an emphasis on places rather than people, and on material rather than subcultural explanations, seemed both politically and ethically forward-looking.



Strange geography of health inequalities

At the same time, however, Sloggett and Joshi (1994) made a strong argument, informed by the experience of 300 000 people in the British census, that individual rather than area attributes are the best predictor of life expectancy; that income redistribution rather than spatial strategy is the appropriate policy solution. This alternative 'radical' view prompted a drive to weigh up the relative effects of places and people in accounting for the health divide. Effectively, the question became:

are geographical inequalities in health and illness just a reflection of socio-economic differences among their inhabitants (composition) or do places add their own contribution to patterns of health variation (context)? (Mitchell et al. 1998, 4)

It was to address this challenge that geographers came onto the scene, frequently employing multilevel modelling to distinguish the statistical effects of factors operating at different levels or (in this case) spatial scales: contexts and composition (Duncan et al. 1998). Using newly available disag- gregated morbidity data, their findings were expected to challenge those of Sloggett and Joshi (1994), who employed standard regression techniques less suited to handling context and composition simultaneously. Pickett and Pearl (2001), however, reviewed 25 multilevel analyses performed on data in the UK, elsewhere in NW Europe and in the USA, referring to mortality, morbidity and health behaviours, and found area effects to be modest, and much smaller than those of composition. The indication from these quantitative studies was that area variations in health are incidental rather than fundamental; that similar people have similar health experiences no matter where they live; that, statistically, composition explains (much) more than context.'

What is perhaps surprising (even strange) in all this is that, undaunted, the social science and policymaking communities persisted with their emphasis on context. The timing was right; it came in the wake of a millennial 'spatial turn' in social science generally. Nevertheless, it is hard to divine precisely what accounts for the tenacity of an approach that seemed statistically so unpromising. Macintyre et al's (2002) spirited defence of place, including a critique of how multilevel models are specified, is undoubtedly relevant. Politicians' determination to move away from the 'victim- blaming' of individual explanations, and the political attraction of a turn to neighbourhoods, may

175

also be important. Perhaps most persuasive, though, is the kind of thinking highlighted by Dorling (2001) in a theme issue of Environment and Planning A on place matters. Under the heading 'anecdote is the singular of data', his argument is that you do not need a geography degree to gain a common sense understanding of the way that place matters for opportunities and life chances. And to an extent this common sense has paid off. Continu- ing to inquire into the character and influence of contextual effects has added substantially to what scholars and politicians know about the geography of health inequalities. In fact, contextual effects have effectively become the geography in health inequalities, and this in turn has dominated research on place and health.

There is, therefore, a still-growing evidence base encapsulating the wide range of subtle and complex ways in which place or context matters for health. This embraces: the spatially selective inter- weaving of 'material infrastructure and collective social functioning' (Macintyre et al. 2002); the geography in 'non-income' dimensions of poverty (Cohen et al. 2003); the controversial health impacts of social capital and human wellbeing (for an overview, see Ziersch et al. in press); and the uneven networks of health-relevant resources that build up or undermine resilience (summarized in Smith et al. 2003). These contextual factors are, moreover, rigorously documented with reference to the full span of qualitative and quantitative research methods used to operationalize and measure 'place effects'. Scholars worry appropriately about sampling strategies (Curtis et al. 2000), boundary problems (Subramanian et al. 2003), and the assignment of causality (Diez Roux 2004; Oakes 2004a 2004b; Subramanian 2004). They engage with techniques combining residential contexts with work experiences (BMland et al. 2002); linking the health impacts of different places across the life course (Wiggins et al. 2002; Curtis et al. 2003); documenting the health effects of a changing geography of deprivation (Boyle et al. 2003); and linking political economy with lay perspectives (Williams 2003). Underpinning all this is an ongoing effort to develop a plausible theoretical infrastructure for contextual accounts. Curtis and Rees-Jones (1998) lay some foundations, interrogating the patterning of physical and biological risks, the content and quality of local social relations, and the meanings attached to space and place. More recently, Popay et al. (1998 2003a 2003b) have offered 'knowledgeable narratives'



176 as a way to link context with composition, while Frohlich et al's (2001 2002) 'collective lifestyles' engage provokingly with Amartya Sen and Martha Nussbaum's reworking of inequality through the notion of capability (see also Anand and Dolan 2005).

This is a rich literature whose store of ideas is by no means exhausted. Moreover, it increasingly fuels a concerted effort across the research community to collapse the false dualism between the 'c'-words. Yet, although human geography generally has worked for some time with the truism that people make places, just as places make people, it is striking how often the story of health and place stops short of embracing this mutuality. Macintyre et al. (2002), for example, make the important claim that differences between context and composition are more apparent than real, but they still write about the whole package as a framework for 'thinking about how places influence health'. Qual- itative methods may offer a more textured account than multilevel models, but they still document 'the impact of social structures on health' (Williams 2003), providing a 'vivid account of the way in which inequalities in material circumstances have an adverse effect upon health' (Popay et al. 2003b, 55; our emphases). The geography in health inequalities is, in the end, mainly about how, in their immense subtlety and complexity, some places (and all the people and things that constitute them, are con- stituted by them, go on in them or even have a bearing on them) are more harmful to health than others.

An important achievement of this line of thought is that it specifies the spatial dimension of a social (rather than individual or medical) model of health, drawing attention to the uneven incidence and systematically unequal effects of a wide range of health-damaging political, material and cultural processes. This social geography has, moreover, proved highly relevant for policy, informing a suite of health-promoting strategies, which, in Britain at least, have been the springboard for a turn away from 'New Right' individualism towards 'New Labour' contextualism. To the extent that place poverty has its own geography and merits its own policy regime (Powell et al. 2001), harnessing the health impacts of 'place enhancement' has been key to a new generation of area-based initiatives, including neighbourhood renewal strategies, community development programmes and health action zones (Pantazis and Gordon 2000). Linking health action with a range of other activities designed to prevent local risks harming local lives


is fully in line with the government's 'joined up' approach to neighbourhood revitalization.

In short, research linking place with health seems a model for policy relevant geography - though it does beg the question of whether a geographical agenda has actively inspired, or is simply legitimizing, the area-based policy turn. Either way, our concern is that this literature, by pursuing what seemed obvious (if, at the time, neglected) about the links between deprivation and health, has produced a strangely one-sided geography. And this, in turn, has informed a peculiarly patchy policy agenda. Einstein apparently described common sense as that 'deposit' of prejudices laid down before the age of 18; what Figure 1 suggests is that by applying this we have produced only half a geography of health inequalities.

The contextual approach in all its richness and diversity remains anchored to the right-hand side of Figure 1. It is about the way that places affect people: by exposing them to risky or protective, disabling or enabling, environments; by locating them in or out of reach of formal and informal care; by enhancing or undermining their resilience and quality of life. To complete the agenda, a different conceptualization of health inequalities is required: one which accommodates the way health histories and conditions themselves (through their encounter with markets, institutions, political norms and cultural expectations) impact on life chances and opportunities. This is represented in the left-hand side of Figure 1. This part of the circuit is not new for human geography more broadly, with its longstanding interest in how different essentialisms are institutionalized in ways that bias people's life chances (see Smith in press). So it is surprising that the geography in health inequalities is rarely thought of in this way. This may reflect a patchy evidence base, although contextual geographies had an equally (perhaps more) unpromising statistical impulse. The argument we prefer is that these undeveloped compositional accounts draw attention to an explanation for health inequalities - rooted in ideas about health selection, or more appropriately health discrimination - which 'common sense' has set aside for some powerful, politically implicated, reasons.

Compositional geographies? Because the geography in health inequalities is so often defined contextually, compositional accounts



Strange geography of health inequalities 177

|Unfavourable | ik/Disablin| 'selection' Risky

Context PLACES

Healthy/Enabling

Favourable 'selection'

Interaction of health capital Inequalities in environmental (health histories, health conditions quality, social support capacities, and health potential) with access health care services and other

rules for different parts and health risks and health-promoting tenures of the housing stock resources, across space and

over the life course

Healthy/Resilient/Enabled Good quality/ easy access

Composition l j Poor quality/

ll/Disabled limited access

Figure 1 Exploring the links between context and composition

rarely feature in the health and place literature. This is not to say that the people side of the equation is neglected: there is a vibrant tradition of participatory research concerned with health identities and living with illness. For the most part, however, to the extent that compositional perspectives figure, they appear in a strand of longitudinal thinking which attends to one kind of biographical or life course approach to health (see, for example, Davey Smith 2002). The emphasis here is on what characteristics, behaviours or events put people's health at risk (or, more recently, with what bolsters their resilience). And this is still, at root, a contextual approach, concerned with how risks cluster across the life course even as they vary over space. There is some geography here: showing, for example, that where people come from (and particularly the circumstances they lived in as children) has a bearing on health outcomes (Curtis et al. 2003). What is missing, however - just as it is missing from the contextual geographies described above - is a sense of how biographical outcomes

are themselves influenced by health trajectories. There is little sense of when and where health is used as a marker of inclusion and exclusion; there are few accounts of the way health histories might set the parameters for employment, housing, wealth and health futures (but see Airey 2002 2003). There are perhaps three interlinked reasons for this.

The first is a tendency towards health sub- disciplinism, which Asthana et al. (2002) have also flagged, and which is surprising, given the genu- inely interdisciplinary impulse behind the reconsti- tution of health geography more than a decade ago. Yet human geography has a longstanding interest in the way social difference is made in, and through, spatial practice and this is not fully reflected in the health inequalities literature. There may be a resurgence of interest in the social and spatial processes by which deprived people cluster into risky spaces (Mitchell 2001), but the possibility that people whose health is already compromised might actively be placed into deprivation is rarely entertained. At best the wider literature is confused,



178

using 'disadvantaged' and 'in poor health' as if they were similar and interchangeable, so masking the way health conditions may be 'mapped onto' places by people as they negotiate a path through the markets and institutions that shape and encase their lives. Contextual geographies of health thus seem strangely disconnected from wider disciplinary concerns with, for example, the power structures that link discrimination and inequality.

Second, for people's 'travels' to provide a partial explanation for the spatial patterning of morbidity and mortality, for health histories to have a bearing on locational futures, spatial mobility would have to be 'health selective'. Although there is a sprink- ling of literature on this, it has not been a popular idea. This is partly because appropriate data have not been available. It has, for example, only just become possible to track between British censuses using health variables, while the main source of longitudinal health data2 - the British Household Panel Survey - has a quite large 'smallest' area of resolution (Brimblecombe et al. 2000). Then there is the way selection has been written out of the quantitative 'contextual effects' literature. Here, health-related mobility is treated as a statistical complication rather than a substantive finding. As Oakes puts it: 'If neighborhoods are imagined to be treatments that affect health, then the "selection" of people to them confounds effects estimates' (2004a, 1932). It follows that:

the selection issue (the fact that persons may be selected into neighbourhoods based on individual attributes which are themselves related to health) is the key problem in observational studies of neighbourhood effects. (Diez Roux 2004, 1953)

This is part of a wider methodological debate which is centrally concerned with the difficulty of imputing causality from statistical analyses, yet which, ironically, leaves the conceptualization of health effects (as outcomes rather than explanatory variables) strangely undisturbed. In consequence, the whole enterprise is driven by the need to 'control' for selectivity rather than account for it.

Even more intriguing is the elliptical, indeed uncomfortable, way in which the migration literature is unfolding: it is as if a paradigm is about to shift but no one dare grasp it. Boyle et al., for example, test data from the 1991 census specifically to establish whether or not 'ill people' are 'more likely to drift towards deprived places' (2002, 22). They argue that (in Scotland) migration does not


exaggerate the relationship between deprivation and limiting long-term illness, even though they provide some interesting evidence of health selectivity in short-distance migration, especially in more deprived areas. Documenting the changing pattern of (ill) health in Northern Ireland, O'Reilly and Stevenson (2003) make the strongest case yet that health-selective migration (rather than any change in the health of individuals) could be a major factor. Yet they regard it as something to adjust for, rather than as a process in its own right which raises new social and political questions.

Norman et al's (2004) paper marks a shift of tone, unpacking the Longitudinal Survey spanning a period 1971-1991 to show that migrants who moved from more to less deprived locations are healthier (now) than migrants who moved from less to more deprived zones. Referring to 'counter- currents of less healthy people', this article affords a new centrality to health-selective mobility. Indeed, from discussions at conferences, email exchanges and other personal communications, our impression is that, after a long period in which selection in spatial mobility was termed 'drift' (as if it happens by accident), labelled 'artefactual' (as if it detracts from the way place affects health) or passed over as the 'healthy mover' effect, social and population geographers may now be ready to explore the possibility that migration is health- selective in some way (a point picked up by Boyle (in press)).

This is all tied up with a third reason why compositional accounts of the geography of health inequalities are so poorly developed: a longstanding aversion to 'health selection' in the world of social medicine. The Black report dismissed it; the most influential subsequent explanation for the patterning of health inequalities - linked with the work of Richard Wilkinson (1996) - was set up in opposi- tion to it; and the radical edge of health research has treated it as a thesis ('reverse causation') which detracts from (rather contributes to) the political and economic questions foregrounded in other explanations. Notwithstanding the plausibility of a case made over a decade ago (Smith 1990 1991; West 1990), a cautious and qualified change of heart in some other parts of the literature (Blane et al. 1993; Macintyre 1997; Cardano et al. 2004), and growing evidence of health discrimination in the labour markets of neo-liberal political economies (Easterlow and Smith 2003a), there is still resist- ance to the idea that health itself might affect



Strange geography of health inequalities people's opportunities and rewards. From the point of view of policy engagement, moreover, this is entirely consistent with governments' agendas. In England, for example, the possibility that poor health might lead to social exclusion was raised in the Green Paper Our healthier nation (Secretary of State for Health 1998), but omitted from the final policy document (Secretary of State for Health 1999).

To summarize: what we know about the 'compositional' element of the link between health and deprivation is minimal compared to the rich tex- ture of 'context'. So although there is only limited evidence for health selection in some of the larger datasets (Benzeval and Judge 2001) - the same sources which described contextual effects as weak - there is a case for exploring the compositional aspects of health inequalities in a more fine- grained way. To this end, the remainder of the paper charts a 'people's' map of health inequalities. It is an attempt to think more seriously and com- prehensively about how, why and to what extent people with different health experiences, whose health is at risk in different ways, are differently and unequally positioned in society and in space.

Assembling the jigsaw The vivid tapestry which now characterizes contextual accounts of health is the result of a steady accumulation of qualitative and quantitative research exploring the route from place into, or out of, wellbeing. There is a much thinner weave to the 'compositional' fabric, though when the strands of this approach are brought together, a pattern of how health is placed does begin to take shape. So far, however, this shape is shrouded in a patchwork of contradictory quantitative indicators. It lacks the qualitative depth and integrity of contextual accounts. It has also been less central to policy. Qualitative approaches are, of course, rarely the first port of call for those most exercised by the policy turn in geography (Martin 2001; Dorling and Shaw 2002). However, we suggest that by using qualitative methods to document lay experiences - not least to identify the normative ideas aspired to and enacted in everyday life - research can make a difference, challenging received wisdoms, redefining common sense' and protecting public health. We develop these themes by drawing, as an

illustration, on the health experiences of people moving through different parts of the British housing system. Housing is central to the geography of

179 inequality (Smith 2000), including the geography of health inequality, which is generally measured with reference to residential location. If Britain is a spatially dividing nation, which the recent census suggests it is (Dorling and Rees 2003), then the fact that 'neighbours' are increasingly similar while neighbourhoods are ever more different is funda- mentally about the way housing systems work. So alongside a well-established literature exploring the health impacts of housing conditions, we would argue - from a 'compositional' perspective - for an approach accommodating the way health experiences impact on housing outcomes. We have already explored this 'selectivity' conceptually (Smith 1990 1991), in empirical studies focusing on social renting (Smith and Mallinson 1997; Smith et al. 1997) and owner occupation (Easterlow et al. 2000; Smith et al. 2004), and in relation to housing policy (Easterlow and Smith 2003b). Below we use data from one of these projects - a study of health and the housing market - to sketch the contours of what, for the moment, we are calling a 'compositional geography' of health inequalities. While the new vogue for studies in health and migration is one part of our thinking, the wider challenge is to link diverse bodies of work on population migration, residential mobility and health selectivity together, within a framework which positions health as an axis, rather than simply an outcome, of inequality. To this end we are interested in the subtlety, diversity and complexity of the many processes by which health histories, employment trajectories and housing paths are linked.

The text below draws on the housing and neighbourhood trajectories of 84 households experiencing long-term ill health in three case study areas in Scotland, Northern England and Greater London. These locations were selected for their contrasting housing, labour market and socio-economic characteristics. Households were recruited on an opt-in basis via a range of health interest groups and housing agencies. By design, all participants have some experience in accessing owner occupation: most owned or were buying their home at the time of interview, though ten were not (yet) first-time buyers, and seven had left the sector. Importantly for the illustrative purposes of this section, the recruitment process and interview checklist were both designed to chart the widest possible range of pathways through the housing system.3 Some of this breadth is shown in Figure 2, which takes the (74) households in the study who have ever owned



180 Susan J Smith and Donna Easterlow

(Risky) Spaces People (Healthy) Spaces

Selective D E Placement I N T T RL

23as_ 29a 2 C

P Copsto:eprinigilhat

ME

..............2

NE T BP-,N

T

Onset, persistence or progression of ill health

Composition: experiencing ill health

Composition: no reported symptoms / diagnoses

Z Context: higher than average local rates of long term illness

E Context: lower than average local rates of long term illness

Figure 2 Placing health

as its starting point.4 The bar at the centre of this figure differentiates between the (35) homeowners whose experience of long-term ill health predated their entry to owner occupation, and those (39) who developed one of a range of health conditions following home purchase.' The interviews have a quantitative as well as qualitative component and by attaching small area census data to residential postcodes, as well as drawing from interviewers' logs and interviewees' self-completed question- naires, it is possible to group study participants according to the 'health profile', and other contextual detail, of their locality. Capturing a small part of this, Figure 2 additionally differentiates between those (29) households who (at the time of interview) were both experiencing ill health and living in small areas with above average rates of limiting long-term illness6 and those (25) who, despite

reporting one or more health conditions, lived in disproportionately 'healthy' contexts. These placements are represented by the ellipses on the left- and right-hand sides of the figure.'

This figure does not represent the entire dataset in the study, but it does draw attention to the three sets of 'health selective' trajectories which form the heart of our discussion: the selective placement (A) of (13) people whose health is impaired, as well as of (16) households whose health is (retrospectively) at risk, into localities whose rates of long-term illness are already high; the segregation or entrapment of (23) people experiencing ill health within these same neighbourhood types (B); and the actual or potential displacement of (12) households experiencing ill health from neighbourhoods whose rates of long-term illness are low (C). We are working with qualitative data, so establishing the relative




'volume' of flow is not our objective.8 Neither is it our aim (here) to provide a fully comprehensive account of how health histories (and prospects) might affect people's geographies. What we are trying to do in this paper is to illustrate, with reference to a spread of lay experiences, the diverse processes and mechanisms by which people whose health is impaired might selectively be sifted and sorted across the housing stock. Our argument is that the scope for such selectivity, and its consequences for people's lives, is about the conduct of politics, the design of institutional policies and the management of organizational practices. Our strategy is to show that this scope exists, by charting the routes of people with and without known health conditions into the more and less risky spaces of home ownership. While these pathways provide one starting point for the kind of 'compositional' geographies which we think are important, they are not, of course, an end in themselves. We are conscious of the extent to which these sketches abstract people and their health from the social networks, lived and material cultures, and embodied identities which contextualize the entirety of their lives. What follows is, nevertheless, a step worth taking in a bid to position the health divide as a marker of discrimination as well as an index of risk.

Selective placement We begin with the stories of those 13 households (group A) who, having already developed one or more adverse health conditions, bought homes in neighbourhoods with above-average rates of long- term illness. Their pathways express a range of individual family, health, employment and social circumstances, but they have some things in common. These stem from the practices by which health conditions materialize into unequal incomes and uneven housing 'careers'; from the processes which nudge people experiencing ill health gradually, but disproportionately, towards similar kinds of spaces.

Seven of these households bought into the two relatively high-cost urban case-study areas in London and Scotland. Three characterize themselves as lifetime renters who effectively chanced on ownership. They were able to buy in these 'expensive' regional locations because they were formerly council renters who changed tenure in situ, for a discounted price.9 As tenants, none had moved into their present homes by claiming priority on health grounds, even though they are all experiencing long-term illness. This means (in contrast to

181 those who did use the 'medical priority' route) that they are unlikely to have acquired the best of the former council stock (Smith et al. 1997). So although they describe their shift from renting to owning as cost-effective and a step up the housing ladder, they live in pockets of properties where rates of long-term illness are high. These are neighbourhoods which, by the 1990s, were still predomi- nantly rented, mainly because they contain properties which are low enough in quality and value to be part of the well-documented residualization of council housing (the classic text being that of For- rest and Murie (1988)). Ironically, it is this residual concentration of social renting which sustains high rates of long-term illness in the localities concerned. Now that so much of the social rented stock has been sold to sitting tenants, families rehoused for health reasons are increasingly likely to be 'steered' by social landlords into these more marginal remaining tenancies. This sequence of events, which accounts for some of Boyle et al's (2002) findings, is indeed illustrated by three of the renters in the current study. They each left home ownership after securing priority access to social renting on the strength of their health-related needs. None feels they 'chose' their destination and all were relo- cated into neighbourhoods with high rates of limiting long-term illness. In discussion they are acutely aware of their limited options in a sector where 'everything decent has already been sold'.1?

The remaining four of those who bought into poor health-profile neighbourhoods in high house- price regions (while themselves experiencing long- term illness) all report personal, family and local social traditions of ownership. They were in a sense predisposed to buy. However, key to understanding their move into what, contextually, look to be 'unhealthy' places, is the pressure they felt to trade locational preferences for affordable properties that meet their various needs. These study participants speak of feeling caught between 'special' schemes in the social sector and poor standards in owner occupation. Pursuing the latter route, they now cluster within post code addresses described by MOSAIC11 as 'low rise subsistence'. As home buyers, they are weighing the emotional boost of independence against the high costs of home main- tenance and repair, and the disadvantage of limited access to both transport networks and shopping facilities. Their lives seem in the balance. Trading location for space has been a route into ownership, a pathway out of depression and a bid for accessible



182 homes. But equally it has meant exposure to the hazards of emotional and financial stress.

The other six households who exemplify 'selective placement' live in northern England, in a region with low rates of private and social renting and a long tradition of low-cost home ownership. All six have low incomes, reflecting the limited labour market opportunities for people experiencing long-term illness (Easterlow and Smith 2003a). Most live in postcode sectors described by MOSAIC as 'Blue collar owners/smoke stack shift work' and even here, they live at the cheaper end of the market. Their narratives indicate that they were able to buy only because of extraordinarily low local property prices. Two households moved long distances from southern England precisely to take advantage of price differentials (which, in this case, proved sharp enough to contradict the tendency for long- distance movers, on average, to be in good health). Three others have more local roots, turning to home ownership at least partly to secure a wider range of housing options than they experienced as renters. To this end, they may still have compromised on size (securing too few bedrooms for their needs), or quality, in order to accommodate their whole family, or to house relatives in need of care.

While the vignettes sketched above testify to the possibilities for health-selective placement, Figure 2 shows that the study includes an equal number of households (13) who bought into areas with better than average health profiles, despite their history of ill health.12 There are, however, two notable differences in these households' characteristics and experiences when compared to those we have discussed so far. First, those (8) living in 'healthy' neighbourhoods on lower incomes generally got there by 'unusual' routes: they either bought into these areas on shared ownership schemes, in- herited their homes in situ from their parents, or cashed in their pensions to secure an owned home. Additionally, three of this group bought a council tenancy more than 20 years ago - a strategy which in this case did pay off, even though it meant living (as one householder put it) in a 'horrible' house in a 'lovely' area. Second, the five families whose incomes are sufficient to attract a mortgage are all two-adult households having one partner whose income was not (at the time of purchase at least) affected by health concerns, or by their role as a carer.

There is some degree of residential mixing in all neighbourhood types among people who do and


do not live with long-term illness,13 and only a small proportion of people report long-term illness at any point in time (though across the life course the figure is much higher). Nevertheless, it seems reasonable to suggest that some part of the poor health profile of areas with high rates of limiting long-term illness could be conceptualized as the product of 'selective placement'. This term was coined by Pratt and Hanson (1994) to help account for the systematically segregating effect of differences in work practices, and we prefer it to the more neutral language of 'selective migration'. We suggest that 'selective placement' may be an important part of the geography in health inequalities, and that these processes can be effected as powerfully through the housing system as in the labour market. Certainly there is a persuasive argument that a housing system like Britain's, in transi- tion from a relatively even tenure split to one dominated by (a particular style of) market transactions, helps 'steer' people experiencing ill health into parts of the housing stock which are least able to promote health and wellbeing (Smith et al. 2004). The narratives in this section highlight the particular potency of this where more than one adult is touched (directly or as a carer) by illness, and where diverse but adverse health conditions affect single person and single parent households.

Selective entrapment So far we have been concerned with the possibility that people living with long-term illness might be selectively drawn into 'unhealthy places'. Next we turn (additionally) to the narratives of the 16 households depicted in Figure 2 as having moved into an 'unhealthy' context before they noticed symptoms, or had a health condition diagnosed. The changing health profile of this group could, of course, plausibly be accounted for by the traditional range of contextual features - by the way that place affects health. But in fact, only one in four households seems sensitive to this possibility,14 and even here there is a layer of complexity which the place-effects literature sometimes overlooks. Consider, for example, the study participant who had a heart attack after living in a classically 'unhealthy' neighbourhood for many years. It would be hard to find a better illustration of contextual effects at work. Yet compared to the health consequences of where he lived before, this householder finds his current setting positively appealing. He accounts for his failing health with




reference to his previous address, not his current home. This is a health trajectory that brings, as Casey (2001) puts it, 'traces of places' into play,"5 as contextual histories exert their bearing on the geography of health inequalities. Nevertheless, a more pressing theme among this group of households (documented in 12 of the transcripts), is the way their homes and localities became increasingly disabling in the face of declining health. Accordingly, our concern in this section is with the process of selective entrapment: with the reasons why households whose health is compromised stay put rather than move on.

Interestingly, all (13) of those we describe (above) as having experienced selective placement saw their current home as a stepping stone, as a means to an end. By the time we interviewed them, however, only one could speak optimistically about a future move. The rest want to trade-on but see no prospect of doing so. This is also true of at least 11 of the 16 households whose health conditions (and/or impairments) developed after they had bought into their current position, again in areas whose residents experience high rates of long-term illness. In short, the majority (23/29) of those owner occupiers in the study who live in 'unhealthy' places want to move on but find they cannot. This is group B in Figure 2.

The strongest quantitative evidence for health selection in migration points towards the possibility of selective entrapment within deprived or declining neighbourhoods among people experiencing ill health. O'Reilly and Stevenson (2003) calculate that the 'residual polarization' produced when healthy people leave deprived neighbourhoods could 'play a significant role in explaining the divergent health trajectories of areas'. However, while quantitative studies using standard sources cannot cast light on the mechanisms which account for this, qualitative research can. What is it about the interaction between health experiences and housing processes that makes certain places 'stickier' for some people than for others? A close reading of 23 transcripts identifies three, often overlapping, sets of factors.

The first is financial. This is about the way in which living with illness can increase day to day expenses and depress incomes. When coupled with the uneven patterning of house prices, and with variations in house price appreciation (and depre- ciation), this can be a powerful brake on mobility. Fourteen of the owners living in areas with high

183 rates of long-term illness are stuck there for some mix of financial reasons. Some accept this is a fact of life, saying their current circumstances are beset by 'niggles rather than problems'. They regard the prospect of moving on as little more than a dream; as the way they will spend their lottery winnings. Others, however, find their circumstances severely limiting; they speak in distressed tones of being boxed in, and they feel stranded as their 'neighbourhood goes downhill'. This sense of decline is potentially a health risk in itself as well as a factor encouraging others to move out (Kearns and Parkes 2003; Parkes and Kearns 2003). Although Britain has (in the past) been distinctive in offering 'medical rehousing' into social renting as an 'escape route' from health-damaging contexts, the gradual closure of this pathway is one of the most insistent messages among lay accounts. As the government has recently empowered local authorities (in England) to assist vulnerable home owners who wish move on (DETR 2000), paying more attention to the way 'entrapment' is experienced seems timely.

A second factor 'anchoring' study participants into potentially risky spaces is the extent to which they have made investments to keep their homes as enabling as possible, notably through the incre- mental yet extensive addition of time-consuming and costly adaptations. For these households, residential mobility is limited as much by the geography of accessible homes as it is by inclination or wealth. They are, in a sense, trading accessibility needs against other aspects of wellbeing. Eight households gave this as a key reason for staying put rather than moving on. Aware that they live in a declining area, they may want to go, but pose the question: in a more widely disabling housing environment, 'where are you going to move to?'

Another angle on this is provided by some of the households who currently rent in areas with high rates of long-term illness. Seven of these have never owned, though all of them would like to. Six of them specifically want to leave the neighbourhood they are in, though only one feels able to do so. The rest are local authority renters who feel threatened and at risk in their current accommodation (partly on account of their health or impairments). What is keeping them there - against the growing trend towards greater mobility among social tenants (Burrows 1999; Pawson and Bramley 2000) - is again the highly adapted fabric in which they live: their experience is that neither owning nor



184 renting contains the range of accessible, enabling properties required to promote equality and diversity across the housing stock. Others are 'stuck' (especially in the London case study) because at the same time as finding ownership unattainable, they have experienced such a lengthy wait for rehousing in the social sector that they feel a move is off the agenda. These households are effectively trapped in a space between 'risk' assessments (applied by lenders, insurers and other financial gatekeepers) and 'needs' assessments (applied by social landlords).

Finally properties are more than bricks and mortar, more than a roof over one's head; they are homes with complex historical and emotional geographies, which are bound into health experiences in all kinds of ways. The very fact of attain- ing home ownership is important to some people as a marker of success: something they have been able to achieve, and which, even if it comes with caveats, offers them a sense of stability. One person spoke of the way her home acts as a reminder of a former, healthier life: 'it's a kind of symbol of what I've been through and I'm desperate to hang onto it'. Furthermore, in societies without a well-developed ethic of care, failing health can be isolating, and moving can act as a symbol of this, severing friend- ships and undermining the social support that is often crucial to those living with chronic illness.

What this all suggests is that selective entrapment is a powerful force, which is not only built into structures and institutions but also ingrained in emotions and imaginations. One entrapped householder observes that people live in this kind of area 'through no fault of their own - apart from life's dealt them a few cruel blows along the way'. Yet, as a second householder notes, it is a cumula- tive process: 'we've ended up stuck here, and then the further stuck you get, em, that's it, there's no way out'. And this viscosity is not just about being unable to influence the markets and institutions which pin people to places. It is a form of dis- empowerment which spills into every part of life. The first commentator, referring as much to herself as to others, notes:

because they're stuck here, they have got the mentality - the stuck here mentality - which means that for their social life, it's not going to the theatre, it's not going out for a meal ... it's not having a leisure time to do nice things.

This practical and ideological 'stick-here mentality', shared by households and institutions, forms an


important part of the attachment that keeps people experiencing ill health in particular kinds of places.

Selective displacement Placement and entrapment are about how people whose health is at risk are routed into and retained within what may be health-damaging spaces. But the study informing this discussion also includes people experiencing long-term illness but living in higher income neighbourhoods with healthier profiles. According to much of the literature, home ownership and health-promoting environments can go hand in hand (e.g. Macintyre et al. 1997; Ellaway and Macintyre 1998). This might be an enticement for the 13 households who moved to 'healthy' neighbourhoods despite experiencing illness, though it seems paradoxical for the 12 study participants who developed health conditions notwithstanding their ostensibly therapeutic setting. What is most striking, however, is that of the 25 households in this study who live in areas with lower than average rates of long-term illness as many as half (12) feel pressured to move on."6 These form group C in Figure 2.

Although migration studies have followed healthy people out of deprived, health-damaging, spaces into better homes and neighbourhoods, they are less able to speak about the experiences of less healthy people living in what should be therapeutic places. Indeed, very little attention has been paid to the possibility that some neighbourhoods have healthy profiles because they exclude or eject 'unhealthy' people: because some health conditions make it hard to sustain the costs and demands of anything but the lowest rung of the housing ladder. Lay experiences, however, testify to at least two sets of reasons (both related to incomes and housing costs) why these households may be at risk of displacement from what are, on the face of it, health-promoting environments.

The first concerns the financial consequences of a wider biographical disruption associated with the onset of ill health. This is about the interaction of health with opportunities for paid work, as well as about the gap between public and private safety nets following accident, sickness or unemployment (Ford et al. 2003). The processes concerned are epit- omized in the present study in this vignette of a young upwardly mobile graduate trainee who bought into a promising neighbourhood, with a healthy profile. This interviewee saw home purchase as 'building up some sort of security for your




own future'. As she put it: 'I wanted to jump into that as quickly as I can'. Working in a stressful setting, however, she experienced a range of symptoms prescient of depression. This, she felt, was linked to the demands of her job. In the end, this was not the kind of work she wanted. Nor was it the kind of employment that wanted her: 'I left the job because I didn't want to become ill ... [but] it was a forced resignation'. The depression did develop, but despite buying some key insurances at the time of home purchase, and notwithstanding some stressful haggling with providers, none of them paid out. Additionally, she 'locked horns with the Benefits Agency', leading to a position where: 'At some point in the near future ... I'm going to have to sell ... and move into rented accommodation'. This example is unique to one interviewee's biography, but it illustrates more broadly the way that health conditions can cascade into many other facets of life, health and place. This cascade is a direct consequence of the way work, safety nets, housing systems, indeed the whole range of markets and institutions in which everyday life is encased, so carelessly interact.

A second recurrent theme among those faced with displacement is the limited suitability and adaptability of even the better quality housing stock. In order to meet accessibility needs, some feel intense pressure to leave owned neighbourhoods which otherwise suit them well and which they struggled to attain. Ironically, this struggle often leaves insufficient funds for anything else, and it certainly rules out the extensive adaptations required to create a lifetime home. This group signal the problems of living in a nation of home owners with, perhaps, too much wealth concentrated into bricks and mortar: 'I really just stretched myself as far as I could stretch myself, and bought this'. Households whose mortgages are at a maximum can feel pressured by the costly inflexibility of their homes to leave spaces which otherwise suit them well: where the neighbours are quiet, friendly and supportive, for example. One person who sees moving on as the only option says it is hard to imagine where he will end up because 'I'm in a best area already'.

The biographies of three study participants exemplify the next steps for those displaced in this way. All of them were once owners but left that sector because they secured priority for rehousing into the rented sector on account of their health- related and accessibility needs. Despite (or because

185

of) this priority they all live now in areas where rates of long-term illness are relatively high. Although they do have homes which are less disabling than before, they are all conscious of sliding down the housing ladder: one speaks of trading owning for renting as a move 'from Hollywood to the Bronx'. All three recognize that they have ended up in their current position 'through circumstances and not through choice'. Not everyone forced to leave relatively healthy owner-occupied settings can, or wishes to, secure a social tenancy. But even a move within owner occupation seems less likely to take them up the housing ladder than down the track of selective placement: to the point at which we began this overview.

Deconstructing the health divide

We have developed this discussion of health- selective placement, entrapment and displacement in order to make the case for a 'compositional' approach to the geography in health inequalities. This does not mean that we advocate detaching the characteristics people carry with them from the environments they travel through, even though this distinction has obvious practical appeal. Neither does our 'take' on composition equate to a standard biographical or life course approach to health, though it does complement these perspectives. Our aim, rather, is to direct attention to the way that health histories and conditions are powerfully entangled with people's trajectories into, within and out of, different spaces and places. These (dis)placements are not statistical artefacts, aimless drift or individual characteristics. Rather, they represent the rich variety of complex ways in which health histories are systematically and unequally mapped onto housing outcomes. They therefore tap into the extent to which direct and indirect health discrimination is enacted in a society which is not care-full enough.

This perspective requires us to revisit and enlarge what has previously been marginalized as a 'health selection' approach to the way key markets and institutions work. This marginalization is, we suggest, less about the evidence base and more about the politics of policy-relevant research. The shift in Britain from neo-Conservatism to New Labour's neo-liberalism has re-invigorated a concern for health inequalities, and policymaking in this sphere has sought out, and benefited from, a contextual, area-based account of how such inequalities



186 are generated and reproduced. This policy agenda has, effectively and usefully, become anchored in a 'social geography' model of health. That is, it re- cognizes the health relevance of collective experience along a socially structured and spatialized gradient, cementing a welcome shift away from the individual victim-blaming of earlier lifestyle- behaviour perspectives.

But the area-based policies this inspires (or is inspired by) are less costly (politically as well as financially) than wider moves to structural adjust- ment, and contextual accounts of health inequality are complicit with this economy. They encourage and inform a politics of health whose strategy for wellbeing hinges around prevention (for the healthy majority) and cure (for the 'sick' minority); they therefore slot into a vision of nationhood founded on fit, able, bodies and a healthy productive work- force. This is a vision so pre-occupied with the task of 'Securing good health for the whole population' (Wanless 2004), so engaged with the project of 'Choosing health?' (Secretary of State for Health 2004), that living with illness is regarded as an unwelcome, and essentially passing, blot on the epidemiological landscape. Illness is a problem to eradicate rather than a way of life to appreciate, a biographical inconvenience rather than a politics of inequality.

It is, then, a strange academic geography which, when talking about health, remains caught in the paradigm of how places affect people. Our complementary contention is that health inequalities are marked out, and made to matter, through spatial practice. We suggest that place matters for health at least in part because housing systems and labour markets are discriminating mechanisms operating in careless societies. Of course, no single set of dis- criminatory practices - selective entrapment, selective exclusion, selective displacement - can, in isolation, explain a high proportion of the health divide, in society or over space. Just as no single contextual influence achieves this goal. But the processes we have identified point broadly and insistently to the interlocking processes and ideas which undermine the entitlements, under-provide for the needs and compromise the aspirations of people living with illness. They point to some systematic reasons why countries like Britain fail to achieve the goals of equality and diversity in the residential order and in society as a whole. They also provide a framework for future research in which the categorizations, discriminations and iden-


tifications formed around health and illness receive as much attention as other axes of inequality, both in theory and in practice.

To this end, we argue that it is to the ethics of care as much as to the practicalities of policy that a more rounded health geography might speak. By this we do not simply mean charting the geographies of formal and informal care, though this has a role to play (Shaw and Dorling 2004). And we refer to more than the 'turn to care' so helpfully signalled by Parr (2003): this literature too often concentrates on the apportionment of responsibili- ties between families, communities and social policies rather than engaging with the political geographies of states and, especially, markets. We are looking additionally for a more comprehensive framework encouraging research and policy to attend to the carelessness practised against people experiencing a wide range of health conditions, mental agilities and bodily capacities.

In this respect, our argument is allied with those developed by writers, including geographers, working with a social model of disability. This model (unlike the social model of health) was developed to account for processes of discrimination, social exclusion and marginalization. How- ever, it was developed to resist the 'medicalization' of lives whose bodily impairments may not be linked to illness events or episodes (the classic text is Imrie (1996); see also Handley (2003)). So while disability theorists might argue that people with impairments are disabled when they encounter environments (social and built) crafted and managed by an ableist society (see, for example, Morris 1991; Madigan and Milner 1999; Imrie 2003), we are further concerned with the way in which people experiencing chronic and long-term illness are disadvantaged by a 'competition society' whose workings are incompatible with an ethics of care (see also Easterlow and Smith 2004; Smith and Easterlow 2004).

In geography, Isabel Dyck and Pamela Moss have paved the way to this rapprochement by drawing on disability theories to understand the experience of chronic illness (Dyck 1995 1999; Moss and Dyck 1996; Moss 1999). This forms part of an emerging debate between (some) medical sociologists concerned with illness experiences and (some) disability writers (see, for example, Williams 1999; Mulvaney 2000). However, our further aim in drawing attention to the discrimination model of health is to build another type of alliance. This




urges closer engagement between health- and disability-discrimination perspectives, on the one hand, and work on health risks and their management, on the other. How place affects wellbeing, why geography matters for prevention and cure, is barely half the health agenda: the rest is about securing the entitlements, embracing the concerns, realizing the hopes and promoting positive recog- nition for those living with illness.

Acknowledgements

The empirical data are drawn from an ESRC- funded study of 'Health and the housing market' (grant number R 000 23 7960). We are grateful to the many households, interest groups and academic collaborators who were involved in this work. This paper is based on our contribution to the plenary session 'Geographies of deprivation and health; what are the messages for health policy?' at the RGS-IBG Annual Conference in London, in September 2003. We enjoyed the lively discussion, and additionally appreciate the comments of Isabel Dyck, Mary Shaw and two anonymous referees.

Notes

1 Properly applied, multilevel modelling is a powerful technique, allowing analysts to work with hierarchi- cally clustered data, address issues of scale and explore cross-level interactions between individual and ecological variables (see Jones and Duncan 1995). The conceptual and methodological debates they have engendered are too wide ranging to address here. Our concern is with just one puzzling theme: the fact that they have inspired analysts to explore the weakest (contextual) not the strongest (compositional) among the many effects they detect.

2 Other than the census-based Longitudinal Study. 3 These qualitative interviews were taped, transcribed

and coded for computer-assisted retrieval. 4 The study includes ten renters who have never

owned. None of these is included in Figure 2. Where appropriate, however, their experiences are referred to in the text.

5 The study includes data on each health condition reported to interviewers (ranging from conditions which seem amenable to contextual explanation, such as asthma, cardiovascular disease and depression, to those which are not generally implied in the contextual literature, such as multiple sclerosis and arthritis). All participants additionally completed an SF36, providing a general measure of health across the study.

6 Relative to both local (enumeration districts in England and output areas in Scotland) and national age-standardized averages.

7 To keep discussion manageable, we have excluded the trajectories of (20) households who live in small areas whose rates of LLTI are comparable to either (or both) local and national averages.

8 For example, the fact that the same number of people experiencing ill health are placed in 'healthy' as in 'unhealthy' contexts is a feature of the research design not an index of wider population trends.

9 Between 1980 and 2000 the rapid expansion of owner occupation in Britain was fuelled mainly by the sale of social rented accommodation to sitting tenants.

10 Because this paper is primarily about groups of trajectories, we have not attached pseudonyms to quota- tions. This is a measure to preserve confidentiality across papers.

11 Experian's classification of neighbourhoods, by postcode, into 52 'lifestyle types'.

12 The remaining six households whose health conditions pre-date home purchase moved into areas with a 'mixed' health profile (e.g. below regional but above national average rates of long-term illness).

13 Curiously (again reflecting the limited development of a discrimination model of health inequalities), social geographers have never extended their inter- ests in residential segregation and isolation suffi- ciently to produce measures of spatial dissimilarity between people who report long-term illness and those who do not (but see Polednak 1997).

14 The health-damaging features they identify include: a sense of insecurity (especially due to vandalism), stress from noisy neighbours, other local incivilities, and worry about living in neighbourhoods that are 'going downhill'.

15 Thanks to Isabel Dyck for bringing this to our attention.

16 Most of them (8) are households whose health conditions developed after they bought their current home.

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Strange Geography of Health Inequalities - Susan J. Smith and Donna Easterlow, The - Unknown

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