Geography Compass 3/6 (2009): 2084–2097, 10.1111/j.1749-8198.2009.00284.x The Geopolitics of Disease Alan Ingram* University College London Abstract This article reflects on the increasing use of the term geopolitics in discussions of disease. It notes that although the term geopolitics has been used increasingly often, its precise meaning has not received sustained attention. Neither has it been conceptualized in relation to the extensive literature in critical geopolitics. To lay the groundwork for a more considered understanding of geopolitics in relation to disease, the article elaborates upon the senses in which geopolitics has been invoked in recent literature and links them with themes in critical geopolitics. It identifies three intersecting themes, in connection with which issues of geopolitics have been raised: the spatialization of governance, biopolitics and transnational political economies. In discussing these themes, the article identifies a number of questions and avenues for further research. Overall, it argues that there is considerable scope to investigate further the ways in which disease becomes geopolitical. In conclusion, the article raises a series of questions that may serve to connect research on the geopolitics of disease with debates taking place in and around critical geopolitics and geography more generally. 1 Introduction The term geopolitics has been used increasingly often in academic discussions of disease. The reasons for this are bound up with a broader discursive shift from ‘international’ to ‘global’ health since the end of the Cold War. As disease has increasingly been conceptualized as global, it has also been interpreted as geopolitical. This is most evident in relation to concern about emerging and resurgent infectious diseases such as HIV ⁄ AIDS, tuberculosis, severe acute respiratory syndrome (SARS) and avian influenza. But it is also related to debates about relationships between neoliberal globalization, disease and health. Interest in the ways in which disease becomes geopolitical therefore extends beyond a focus on outbreaks of microbial pathogens to encompass much larger issues. It can be observed that although reference to geopolitics has become increasingly common in discussions of disease, its precise meaning in this context has not received sustained attention. Furthermore, there has been little explicit reference to literature in critical geopolitics, which has developed a sophisticated array of tools for conceptualizing geopolitics. To lay the groundwork for a more considered understanding of geopolitics in relation to disease, the article elaborates upon the senses in which geopolitics has been invoked in recent literature and links them with themes in critical geopolitics. It identifies three main themes in relation to which issues of geopolitics have been raised: the spatialization of governance, biopolitics and transnational political economies. As the discussion shows, these are not exclusive of each other but frequently intersect, in particular around questions of globalization. In discussing these themes, the article identifies a number of questions and avenues for further research which centre on the conceptualization of geopolitics. Overall it argues that there is considerable scope for further investigation of the ª 2009 The Author Journal Compilation ª 2009 Blackwell Publishing Ltd Geopolitics of disease 2085 ways in which disease becomes geopolitical. In conclusion, the article raises a series of questions that may serve to connect research on the geopolitics of disease with debates taking place in and around critical geopolitics and geography more generally. 2 The Spatialization of Governance A growing body of scholarship across a number of disciplines has been concerned with the spatial practices manifested around problems of disease. The work of the historian Alison Bashford is relevant in particular in terms of her conceptual engagement with questions of space. Her earlier work and collaborations with others (Bashford 1998, 2004; Bashford and Hooker 2001; Strange and Bashford 2003) have shown how anxieties over infectious disease, and resulting practices such as isolation and quarantine, are not simply functions of technical knowledge, popular fears or media-generated scares, but form part of much broader processes of place-, nation- and world-making. These processes are in turn understood as being permeated by ambiguities of identity and the circulation of power. More recently, Bashford (2006a) has used the term geopolitics to signal a number of features of the way disease has been governed in the context of globalization from the mid-nineteenth century to the present. In particular, Bashford (2006b) seeks not only to historicize, but also to spatialize understanding of current, ‘global’ health practices. As she states, ‘‘analysis of global health raises a history of medicine, but it also raises a history of geopolitics’’ (p. 1). But what specifically does the term geopolitics denote? Although Bashford uses the term geopolitics, she does not conceptualize it in relation to literature on geopolitics itself, or critical geopolitics in particular. Rather it is used in a more general sense to signal particular features of global order and disease governance. Here, I identify four broad meanings of geopolitics in Bashford’s work, before considering other deployments of the term in research on the governance of disease as a security issue (see Table 1). For Bashford (2006b, 1), the term geopolitics makes reference, first, to a divided world, where the manifestly unequal distribution of the benefits of modern medicine and public health marks the division between North and South, West and East possibly more starkly than any other factor. This situates disease and strategies against it not just in the context of formal inter-state relations or the operation of global institutions (as in much of the literature on health in international relations and global governance), but in terms of spatial dynamics of inclusion and exclusion, of wealth, power and domination. Disease is geopolitical in that it emerges and is governed in a world that is spatially uneven and unequal, and responses to disease are positioned as constitutive of particular kinds of space as well as reflective of them. Second, Bashford indicates that governing disease is geopolitical in that it involves the making of borders and the separation of things, people and places that would otherwise mingle, interact and transform each other. In other words, it is taken up with the sociospatial management of contagion (Bashford and Hooker 2001). This is evident, for example, in successive inter-state agreements, which have sought to restrict the regulation of transnational infectious diseases in terms of technical criteria and minimal disturbance to trade and travel. However, the governance of disease intersects in multiple ways with racialized, gendered, sexualized and classed categorizations and formations of power ⁄ knowledge. Transborder ‘global’ health issues also unsettle the imagination of ‘national’ health, and provoke its reimagination (Craddock 2008; Ingram 2008). But ª 2009 The Author Journal Compilation ª 2009 Blackwell Publishing Ltd Geography Compass 3/6 (2009): 2084–2097, 10.1111/j.1749-8198.2009.00284.x 2086 Geopolitics of disease Table 1. Spatialization of governance. Source References to geopolitics Bashford (2006b) ‘‘This is a modern history of … a divided world … The geopolitical aspect not only concerns the historical geography of disease itself, but also that of disease management’’ (p. 1) ‘‘Infectious disease management often has spatial implications, and uses spatial measures’’… ‘‘For this reason, borders of many kinds, and in many places, so often recur in practice’’ (p. 1) ‘‘infectious disease control … has not infrequently been a rationale for all kinds of formal and informal intervention beyond a local jurisdiction, beyond a sovereign state’’ (p. 2) ‘‘While once disease prevention and geopolitics were simply related, more recently the former has become a vehicle for, and even instruments of, the latter’’ (p. 2) Of the imagination of tuberculosis in the United States: ‘‘Even the definition of risk and ‘high-incidence’ must be seen as shaped by a confluence of geopolitics, state demographics, public health resources, and social political ideologies rather than simply as a scientific standard’’ (p. 190) Argue integration of public health and counter-terrorism represents a ‘‘neocolonial agenda that must be questioned for the sake of constituting public health as a global public good’’ (p. 242) ‘‘Global public health surveillance is not organized around a concept of an external frontier to be defended. It is ‘empire’ without an outside rapidly being integrated into the intelligence needs of the Global North’’ (p. 259) Craddock (2008) Weir and Mykhalovskiy (2006) while bordering practices in response to disease are geographically complex they are also politically polyvalent: they can be associated with colonial control and reactionary nationalism as well as inclusive citizenship or technocratic and humanitarian discourses; indeed, each of these has been bound up with the others (Ticktin 2006). The third sense in which the governance of disease is geopolitical for Bashford (2006b) lies in the intersection of bordering with the global projection of power. As she states, disease management ‘‘has not infrequently been a rationale for all kinds of formal and informal intervention beyond a local jurisdiction, beyond a sovereign state’’ (p. 2). Ensuring ‘national’ health has often meant pre-emptive intervention by actors with ‘global’ reach, in an attempt to contain disease threats. Such interventions have typically been legitimated in a variety of ways at the same time, in terms of insuring both ‘homeland’ and ‘world’ health, but also in terms of strategic interests in particular regions. The promotion of health globally has also been fraught with the assertion and negotiation of cultural and professional power. It has been anything but neutral. A fourth sense in which geopolitics is invoked by Bashford (2006b) and others is specifically in relation to the ways in which disease management has become increasingly bound up with formations of security in the post-Cold War period (Ingram 2005). In particular, concerns have been raised about the place of public health in the US-led war on terror, with analysts identifying close affinities between discourses of homeland security, counter-terrorism and public health (Cooper 2006; Loeppky 2005). It has also been suggested (Ali and Keil 2008; Keil and Ali 2006) that such connections are increasingly playing out in the context of cities. The concern of global health practitioners with the potential of cities to amplify epidemic threats runs parallel to concerns about the urbanization of political conflict (Graham 2004). Although the idea remains somewhat ª 2009 The Author Journal Compilation ª 2009 Blackwell Publishing Ltd Geography Compass 3/6 (2009): 2084–2097, 10.1111/j.1749-8198.2009.00284.x Geopolitics of disease 2087 underdeveloped, it may be possible to speak of an urban geopolitics of disease (Braun 2008) that problematizes cities and urban governance in terms of global health security. A number of further spatial themes are played out in discussions of the governance of disease in terms of security. The collision of global health and security is also explored in the context of Toronto by Hooker (2006). She identifies uncomfortable parallels between the response to the SARS epidemic of 2003 and the war on terror. In particular, she argues that ‘highly conservative’ practices of containment were instituted in Toronto which went well beyond what could be justified by the public health evidence base, and which worsened pre-existing patterns of stigmatization. She associates these practices with a shift from rationalities of risk to rationalities of danger in the context of epidemic threat. Weir and Mykhalovskiy (2006) raise similar concerns about the integration of global public health surveillance with counter-terrorism, this time in terms of empire and neocolonialism. In particular, they are concerned by institutional affiliations between certain global health surveillance networks and military and security agencies. Evoking Hardt and Negri’s (2000) account of empire, they suggest that the world of global public health surveillance is less the ‘new way of working’ hoped for by global health officials (Heymann, cited in Fidler 2005) than ‘‘‘empire’ without an outside rapidly being integrated into the intelligence needs of the Global North’’ (Weir and Mykhalovskiy 2006, 259). Reflecting on the spatial formation of global health governance, Hooker (2006, 192) raises concerns about a US-centric approach to biosecurity in which national borders are reproduced, as they were during SARS, yet deterritorialization is used as a resource for extending US security and hegemony. These accounts raise important questions about the forms of geopolitics found within global health, particularly as they have been manifested in relation to security. These concerns will be familiar to scholars of geopolitics, yet they have been articulated largely without reference to work specifically in this field. There has been little reference, for example, to ideas of geopolitics as discourse (Dalby 1990; Ó Tuathail 1996) or a mode of envisioning (Agnew 1998) or to work taking up the geopolitical formations arising out of globalization (Ó Tuathail and Dalby 1998). There is therefore much potential to explore such avenues. However, it is also necessary to take account of the recent development of other concepts that have been used in tandem with geopolitics as a means of theorizing problems of disease. Salient among these is biopolitics. 3 Biopolitics Ideas of biopolitics have become important to a wide variety of intellectual agendas, including critical geopolitics (Campbell 2005; Schlosser 2007, 2008). Most recent discussions of biopolitics take Foucault’s formulation of the term as a starting point. Foucault (1998, 2004, 2007) used the word biopolitics to signal a form of power which he argued became increasingly significant to the constitution of Western European societies from the seventeenth century onwards. For Foucault, biopolitics is not ‘deductive’ (like sovereignty, which has to do with the taking of life) but productive (being concerned with ‘making live’). In particular, biopolitics is concerned with maximizing the welfare of populations, and is manifested in fields such as urban planning, the sciences of population, fertility and reproduction and public health and insurance. Crucially, for Foucault, biopolitics was a liberal technology of government: it could only truly flourish in contexts where liberal ideas of freedom (of individuals, of the market, of choice) provided a guide for government and wider social practice. As a liberal ª 2009 The Author Journal Compilation ª 2009 Blackwell Publishing Ltd Geography Compass 3/6 (2009): 2084–2097, 10.1111/j.1749-8198.2009.00284.x 2088 Geopolitics of disease technology, biopolitics was also particularly concerned with the promotion and regulation of circulation. As a famous passage dealing with French town planning in the eighteenth century has it, In other words, it was a matter of organizing circulation, eliminating its dangerous elements, making a division between good and bad circulation, and maximizing the good circulation by diminishing the bad. (Foucault 2007, 18) It is easy to see why this passage has been particularly suggestive for scholars concerned with contemporary security practices, which seek to regulate the mobility of a wide variety of phenomena in the context of globalization (Bigo 2002; Ingram, forthcoming). In particular, concepts of biopolitics have been used in tandem with geopolitics to examine the ways particular phenomena are addressed as problems of security (Dillon 2007; Dillon and Lobo-Guerrero 2008; Duffield and Waddell 2006). However, in discussions of disease (notably Braun 2007, 2008; Hinchcliffe and Bingham 2008) geopolitics has not generally been given the same kind of explicit conceptual elaboration as biopolitics; rather its meanings are taken somewhat for granted, or conveyed by a selection of key phrases derived more or less explicitly from other sources. Thus, again, there is scope for further conceptual elaboration and exploration. Braun (2007) represents a key intervention. Braun’s starting point is biopolitics rather than geopolitics, in particular Rose’s (2007) account of the ‘molecularization’ of biopolitics; that is, the ways in which knowledge about life has been revolutionized by advances in the biosciences. For Rose, this means that the biopolitics of population is no longer so significant; rather it is the relationship of the subject to their own health, understood at the genetic and molecular level, which forms the main axis for life politics, in something he terms ‘ethopolitics’. Braun rightly takes Rose to task for his somewhat provincial outlook: ethopolitics is indeed the privilege of a minority of the world’s population. The molecular problem Braun draws attention to is rather the resurgence of infectious disease under conditions of neoliberal globalization. What troubles him is the rise of biosecurity (for example in US homeland security discourse and in the World Health Organization’s idea of global health security) as a means of dealing with the unpredictability of global life at the molecular level. For Braun, biosecurity is biopolitical in the way it seeks to govern life, particularly at the intersections between human, animal and microbial life. But it is also geopolitical in that it also seeks to govern through and across spaces of homeland security and foreign policy intervention. Biosecurity, therefore, ‘‘weds biopolitics with geopolitics’’ (Braun 2007, 23). From this we can see that, like a number of other writers, Braun takes biosecurity to be geopolitical in terms of geographical practices of security at home and abroad in the context of globalization. But there are other meanings of geopolitics in Braun’s account that are worthy of further elaboration (see Table 2). I signal out three in particular. The first is inherent to the geography of biosecurity discourse itself. As King (2002, 2004) has shown, the ‘emerging infectious diseases worldview’ that underpins much security discourse about disease was forged in a geographically specific milieu, namely among US scientific, policy and media communities seeking to craft compelling narratives about the importance of public health following the end of the Cold War, as much as to describe problems scientifically (see also Bell et al. 2006; King 2003; Schell 1997). Biosecurity, then, can be interpreted as an outcome of geographically specific convergences between the emerging infectious diseases worldview deconstructed by King and contemporary security discourse. As Braun (2007, 14) shows, there is here a narrative ª 2009 The Author Journal Compilation ª 2009 Blackwell Publishing Ltd Geography Compass 3/6 (2009): 2084–2097, 10.1111/j.1749-8198.2009.00284.x Geopolitics of disease 2089 Table 2. Biopolitics. Source References to geopolitics Braun (2007) ‘‘public health has taken the body to be a geopolitical body’’ (p. 15, emphasis in original) ‘‘ ‘biosecurity’ today names a set of political responses within globalization that take the unpredictability of molecular life … as their own justification, and in such a way that ‘security’ appears the only viable political response’’ (p. 15) Identifies a ‘‘conjunction of geopolitics and biopolitics’’ in stories that ‘‘that mix together Vietnamese peasants, influenza viruses and homeland security’’ (p. 14) US public health policy pursuing forced integration, ‘‘premised on the idea that the world can be split into a ‘functioning core’ of liberal peace and a ‘non-integrating gap’ within which emerging threats must be suppressed’’ (p. 22) Biosecurity as a bio ⁄ geopolitical rationality as framed ‘‘in terms of the extension of sovereign power by which life is ever more tightly integrated with law’’ (p. 14) Identifies ‘‘patenting of bio-information’’ as a ‘‘modern day form of enclosure’’ (p. 13) Identifies ‘‘conjunctures of geopolitics and biopolitics’’ in US foreign policy discourse on HIV ⁄ AIDS and security (p. 511); geopolitics and biopolitics as ‘‘two sides of the same coin’’ (p. 528) Identifies ‘domopolitics’ (Walters 2004) and biopolitics at work in the exclusion of failed asylum seekers and ‘illegal’ migrants from access to anti-retroviral therapy in the United Kingdom ‘‘it is the complex relations of geopolitics and biopolitics and more besides that forms a vital moment for geographical and social science enquiry’’ (p. 1548) Ingram (2007) Ingram (2008) Hinchcliffe and Bingham (2008) geopolitics to biosecurity in stories ‘‘that mix together Vietnamese peasants, influenza viruses and homeland security’’. Following Gregory (2004, 17–19), we could therefore draw out a sense of geopolitics in terms of imaginative geographies, in that biosecurity involves performances of space that dramatize difference and fold it into distance. At the same time, however, it is necessary to recognize the specificities of global health. These are also stories of closeness and intermingling: in current imaginations of global health, difference is apprehended as threatening precisely by virtue of its actual or potential proximity, whether in topographical or topological space (Braun 2008; Ingram 2008). We can derive ways of thinking about the imaginative geopolitics of disease as well as its biopolitics. The second geopolitical theme comes from Braun’s (2007, 22) observation that US public health policy is pursuing forced global integration into networks of global health security to protect the ‘ ‘‘functioning core’’ of liberal peace’ from threats emerging within the ‘non-integrating gap’. This idea of biosecurity as a biopolitical and geopolitical project of liberal peace is highly suggestive, and worth considering in further depth. Braun’s formulation echoes Ó Tuathail’s (1996, 253) perceptive suggestion that geopoliticians of the future would increasingly be concerned with protecting the ‘tame zones’ of the globe from its ‘wild zones’, but it also plays more specifically upon two further sources. First, the terms ‘functioning core’ and ‘non-integrating gap’ come from the notorious geopolitical vision of Thomas P. Barnett (2003, 2004), which has been subject to scathing critique within critical geopolitics (Dalby 2007; Roberts et al. 2003). The concept of liberal peace has, meanwhile, been developed more substantially and more critically by Duffield (2001) and other theorists (Richmond 2007), some of ª 2009 The Author Journal Compilation ª 2009 Blackwell Publishing Ltd Geography Compass 3/6 (2009): 2084–2097, 10.1111/j.1749-8198.2009.00284.x 2090 Geopolitics of disease whom have examined it as a biopolitical project (Dillon and Reid 2001; Duffield 2005, 2006, 2007). Duffield (2001) in particular is concerned with how networks of global governance have dealt with conflict, state failure and mobility through new rationalities of development and security. He further suggests (Duffield 2006) that development, security and migration control have become increasingly interlinked in a ‘planetary architecture of containment’, oriented around the geopolitical management of two biopolitical zones: the ‘insured’ liberal life of the global North and the ‘uninsured’ life of the global South (Duffield 2007). The effect of international development and migration control is, Duffield suggests, both biopolitical and geopolitical: to maintain a distinction and separation between the two zones, such that the global North can continue its exploitative and ecologically unsustainable existence, while remaining secure from the unwanted effects of global interdependence and circulation. Duffield’s thesis raises important questions about current spatial organizations of power. But to what extent does it allow for the specificities of global health issues, or their geographical complexity? As Ingram (2007) argues in relation to the adoption of HIV ⁄ AIDS as a major issue for US foreign policy, while the conjunction of geopolitics and biopolitics contains the potential for new forms of domination, it may also foster transnational association and mobilization. This suggests that although Duffield’s spatial template is provocative, it provides only a rough guide to the geopolitics of global health, which requires more specific elaboration. The third theme to draw out from Braun’s (2007, 14) discussion is implicit in his suggestion that the geopolitics of biosecurity involves the ‘‘extension of forms of sovereign power by which life is ever more tightly integrated with law’’. Here, there is an allusion to Agamben’s (1998, 2003) discussion of biopolitics (see also Hinchcliffe and Bingham 2008; Schlosser 2008). In contrast to Foucault, Agamben interprets biopolitics as part of sovereign and juridical power, which he argues have always been central to modern Western power. For Agamben, biopolitics is less a threshold of modernity reached in seventeenth- and eighteenth-century Europe than a presence throughout the political history of the West. As has become well known (Ek 2006; Minca 2005, 2006, 2007), for Agamben the paradigmatic spatial manifestation of biopolitics is the camp, a space that exists at the margins of the law, whose inhabitants are within the reach of sovereign power, but excluded from citizenship; they are rather exposed to violence as ‘bare life’. Agamben has (like Foucault) been criticized for his Eurocentric preoccupations, and also for his failure to examine how spaces of exception are opened up and can be resisted (Gregory 2007). But taking such qualifications into account, the complex geopolitical spatiality offered in his work is potentially relevant to the situation of people and places at the margins of global health. This is particularly the case, for example, in relation to people seeking asylum or ‘illegal migrants’ within the West, as much as beyond it (Ingram 2008) (for a critical take, see Comaroff 2007). It is also relevant in view of intensive efforts to bring the government of ‘global’ infectious diseases within the compass of domestic and international law (Fidler and Gostin 2007), particularly so in situations where legal regulation breaks down, is suspended or becomes subject to discretionary power. Consensus has yet to be reached on precisely how countries ought to collaborate in the event of pandemics, particularly around intellectual property and access to medicines (Tayob 2008). Even with agreements in place, there is every likelihood that states will invoke emergency powers to deal with severe public health events, or to counter virtual threats that have not yet materialized (Braun 2007). It is possible that while efforts will be made to allow circulation, practices of containment, confinement and exclusion will be brought to bear with considerable force, but in geographically very specific ways. ª 2009 The Author Journal Compilation ª 2009 Blackwell Publishing Ltd Geography Compass 3/6 (2009): 2084–2097, 10.1111/j.1749-8198.2009.00284.x Geopolitics of disease 2091 Once again, the precise geopolitics of such conjunctures cannot be wholly inferred in advance from existing categories, but remains largely to be investigated and elaborated conceptually. Finally, Hinchcliffe and Bingham (2008) advance a non-anthropocentric approach to biosecurity that interprets it in terms of sociomaterial assemblages. These assemblages include biopolitics and geopolitics but also ‘more besides’ (Hinchcliffe and Bingham 1548). For them, biosecurity emerges out of efforts to order and purify complex political ecologies. They argue that what are most important are the interferences between assemblages rather than any particular logics that might be attributed to them. But although they unpack the potential meanings of biopolitics and other assemblages at some length, they say relatively little about what a geopolitical assemblage, whose interferences with other assemblages are to be the subject of investigation, might be. Geopolitics, although recognized as significant, remains in the margins; the task of conceptualizing and upacking remains. As with work on the spatialization of governance, this overview of ways in which geopolitics has been connected with biopolitics in relation to disease suggests that further conceptual development has much to contribute to an understanding of the ways in which power is projected over people and places around problems of disease. As we have seen in both the preceding sections, a concern with the implications of neoliberal globalization for disease and the ways it is governed is a recurring theme. However, despite the widespread recognition of its relevance and significance, in none of the work discussed so far is neoliberal globalization interrogated in depth. It is to this issue that we turn in the next section. 4 Transnational Political Economies The final theme deals with relations between transnational political economies, disease and health. This theme has already been signalled in the preceding sections: work on the spatialization of governance often takes note of the role of neoliberal globalization in producing the context within which emerging infectious diseases have become an important ‘global’ problem, and the ways in which it complicates efforts to respond to them. Similarly, geopolitics, biopolitics and security are often conceptualized in relation to liberalism and neoliberal globalization. However, it is possible to identify a somewhat distinct approach that places the emphasis more fully on theorizing the ways in which transnational capitalism and associated neoliberal technologies articulate with the production and management of disease and health. In particular, a number of critical accounts have sought to recover connections between neoliberal restructuring and integration and the emergence, not just of ‘emerging infectious diseases’ discourse, but of a much wider global health crisis (Farmer 1996, 1999, 2005; Kay and Williams, 2009; Kim et al. 2000). This approach is part of a much longer and wider tradition of scholarly and activist challenges to material relationships between wealth, poverty, health and associated demands for political accountability (Global Health Watch 2006, 2008; Labonte and Schrecker 2005, 2007a,b,c; Labonte et al. 2004). What is striking is that until recently geographers have made relatively little contribution to such accounts. However, direct links can be drawn with critical geopolitical research on geopolitical economy. Scholars of geopolitics (notably Agnew and Corbridge 1995; Sparke 2008a) have argued that it is insufficient to theorize international political economy without regard to space; rather, space is intrinsic to the operation of ‘international’ (or better, transnational) ª 2009 The Author Journal Compilation ª 2009 Blackwell Publishing Ltd Geography Compass 3/6 (2009): 2084–2097, 10.1111/j.1749-8198.2009.00284.x 2092 Geopolitics of disease political economies (see also Mercille 2009). As Agnew and Corbridge (1995, xi) state, the ‘‘process of disciplining, subjugating, exploiting and developing places’’ is ‘‘intrinsically geographical’’. What remains to be developed is a fully articulated geographical agenda for clarifying how this process might link with today’s landscapes of disease and health. A key resource for such an agenda has been provided by Sparke (2008b) in a deep and wide-ranging exploration of different forms of economism evident in thinking about global health. Although explicit references to geopolitics are rather few, there are direct resonances with ideas of geopolitical economy and the proposition that geopolitics and geoeconomics are closely intertwined (see Table 3). At this point, it should also be noted that it is in tandem with critiques of neoliberalism that feminist analysis has addressed the geopolitical dimensions of global health most directly, for example, in relation to the gendering of vulnerability to disease and the role of feminized labour in producing health care. As O’Manique (2004, 2005) argues, neoliberal globalization and the subordinate position of women have been twin drivers of HIV ⁄ AIDS in sub-Saharan Africa. Major (2008, 1633), meanwhile, argues that embodied and gendered affective labour has become a key site not just for the production of health care, but for ‘‘the renegotiation of urban and global security in the face of emerging infectious disease’’. The biopolitics of labour in such settings, she suggests, is shaped profoundly Table 3. Transnational political economies. Source References to geopolitics Sparke (2008b) Cites ‘‘City spaces, colonial control zones, ‘natural regions’ and national-state territories’ as ‘influential historical-geographical horizons for visualizing both health challenges and arenas for medical action’’ (p. 3) States that ‘‘these older geographical horizons are being revised and reterritorialized’ … ‘in the context of economic globalization, and specifically in relation to today’s increasing extension and entrenchment of pro-market ‘neoliberal’ approaches to government’’ (p. 3) Discussion of Latour references his linkage of arguments for funding health research with the ‘‘national geopolitics of the war against the Prussians’’ and ‘‘the global scale of colonial geopolitics’’ (p. 14, note 3) Identifies how marginalized people and places suffer ‘‘direct geopolitical violence’’ as well as ‘‘structural violence’’ (p. 55) Concern with ‘‘how global health inequalities emerge as symptoms of the deeper tectonic ties and tensions generated by globe-spanning and globe-remaking socio-economic processes’’ ‘‘most analyses of the securitisation of AIDS ignore the broader contributors to human insecurity located in the current global distribution of power and resources, and their relationship to human health, disease distribution and impacts’’ (p. 26) ‘‘A feminist analysis of the ‘security crisis of AIDS’ would begin by examining the relationship between people’s everyday lived experiences and the exercise of power at local, national, and global levels, situating the analysis of risk and vulnerability to HIV ⁄ AIDS, and the multiple impacts of epidemics, in this broader context’’ (p. 26) ‘‘I argue that the bodies of hospital and hotel workers are a central site of the renegotiation of urban and global security in the face of emerging infectious disease: as immaterial work becomes central to accumulation, the biopolitics of labour takes central stage’’ (p. 1633) O’Manique (2005) Major (2008) ª 2009 The Author Journal Compilation ª 2009 Blackwell Publishing Ltd Geography Compass 3/6 (2009): 2084–2097, 10.1111/j.1749-8198.2009.00284.x Geopolitics of disease 2093 by the neoliberalism and managerialism that remake health and health care in many different places. Sparke is concerned to reveal the ways in which different imaginations of health as geoeconomic are not just politically invested, but form part of the reproduction of particular kinds of material space. He thus positions imaginative geographies of global health as part of a dynamic that is geopolitical at the same time as it is geoeconomic, and which has material force as well as epistemological and discursive underpinnings. He identifies three main imaginations of the relationship between global health and the economic sphere under the heuristic labels of market fundamentalism, market foster-care and market failure. Market fundamentalism (evident in the prescriptions of actors such as the G8, World Bank, IMF and WTO) is distinguished by neoliberal postulates: good health, it is argued, is dependent on good growth, entrepreneurial innovation in pharmaceuticals and the market delivery of these innovations to global health consumers. Poor health, in contrast, is seen as a result of poor integration of the networks of global capitalism (Sparke, 2008b, 19). As Sparke shows, market fundamentalism relies on a particular ‘base map’, most clearly expressed in ideas such as a ‘borderless world’, or in the words of Friedman (2007), that The World is Flat. This helps Friedman and others to ‘‘naturalize neoliberal norms and pro-market reforms as the only options available for governance’’ (Sparke, 2008b, 19). When imported into global health, such imaginations obscure the disparities of power underpinning global trade rules, which increasingly impinge upon policy space for health, as they simultaneously open it for commodification and corporate intervention. In turn, health policy becomes less a matter of rights and citizenship, and more one of calculative rationalities of cost-effectiveness, based on contentious and abstract measures such as ‘Disability-Adjusted Life Years’ (DALYs). Ill health then becomes less a problem of justice, than insufficient integration into global markets. Market foster-care, in contrast, apparently evinces a more active concern with the situation of poor people and diseases of poverty. Although it is equally grounded in neoliberal assumptions, it seeks to adjust the global health policy mix to compensate for barriers to health. Furthermore, market foster-care often factors in geography and place-based criteria for deciding how to help the poor. Indeed, using international and philanthropic health aid (invariably technological or technocratic in orientation) to free people and places from dual ‘traps’ of ill health and poverty is seen by market foster-carers (typified most clearly by Jeffrey Sachs) as essential to placing them on the path to economic growth. In Sparke’s characterization, A notably biomedical vision of care is thus twinned with an economic instrumentalism to fashion a therapeutic as well as a so-called enlightened and self-interested investment in the health of the global economy itself. (2008b, 17) As Sparke shows, there are numerous problems with this, not least that with its overtones of environmental determinism, market foster-care compounds the pathologization of particular people and places as diseased and poor, rather than asking whether this is symptom rather than cause of their marginality. Market foster-care therefore fails to challenge the imaginative ‘geography of blame’ (Farmer 1990) for poverty and ill health, while obscuring other political–economic geographies that might account for them. The third imagination identified by Sparke is market failure, which starts from a critique of the implications of neoliberalism for health and a profound scepticism as to ª 2009 The Author Journal Compilation ª 2009 Blackwell Publishing Ltd Geography Compass 3/6 (2009): 2084–2097, 10.1111/j.1749-8198.2009.00284.x 2094 Geopolitics of disease whether markets can deliver ‘health for all’. Accounts of market failure focus more directly on inequality as a historically and geographically constituted pathogenic force in its own right. Ill health and inequality are regarded less as independent variables that may or may not be correlated, than symptoms ‘‘of more systemic processes that produce health vulnerabilities in and, just as importantly, across different spaces’’ (Sparke, 2008b, 48–49, emphasis in original). It is in mapping such processes that Sparke sees particular potential for geographical accounts. Citing the work of the anthropologist, physician and activist Paul Farmer as exemplary of a geographically sensitive approach, Sparke draws out how disease and ill health emerge from transnational, material relations between people and places, often unfolding from the era of formal colonialism through into the present, and the ways in which such relations are overdetermined by racialization and gendering. The challenge Farmer sets, and to which Sparke (2008b, 56) calls geographers to respond, is ‘‘to understand how global health inequalities emerge as symptoms of the deeper tectonic ties and tensions generated by globe-spanning and globe-remaking socio-economic processes’’. Theorists of geopolitical economy would suggest that such processes cannot be separated from broader questions of hegemony, militarism and violence that have often formed the focus of critical geopolitical enquiry. 5 Conclusion Ideas of geopolitics have been used increasingly often in discussions of disease, but considerable work remains to be done to elaborate in depth upon the meaning of the term in this context. Existing research poses a number of issues as geopolitical in relation to the spatialization of governance, biopolitics and transnational political economies. However, these remain to be taken up and pursued in a sustained manner in tandem with literatures in and around critical geopolitics. As wider interest in global health continues to increase, this presents a clear challenge and opportunity for geographical research. Taking up this challenge will involve the negotiation of debates taking place in and around critical geopolitics and geography more broadly. These include, for example, the still-contested grounds between feminist and critical takes on geopolitics. Despite attempts to bridge the two (Hyndman 2004; Pain, forthcoming; Pain and Smith 2008), it remains unclear whether they will in fact become part of a shared project. This has implications for how we go about trying to theorize geopolitics, disease and health, as well as other key concepts like security. Similar debates revolve around relationships between political economy and approaches such as governmentality. Although some theorists aim to bring these together (Jones 2008), others are sceptical as to whether this is viable (Barnett 2005). Actor-network approaches destabilize the objects of theory, in many ways productively (Hinchcliffe and Bingham 2008), but in what ways is it possible to do this while retaining, for example, a politically engaged sense of the force of transnational neoliberalism? There are further questions about how we might integrate investigations of the everyday or emotional geopolitics (Pain, 2009) of disease with inquiries into the spatial reach and impact of the strategies of the powerful. Finally, it should be asked how such research can be aligned more effectively with the struggles of those seeking to address inequities in health. Addressing questions such as these will be central to the development of more comprehensive and more relevant understandings of geopolitics, disease and the intersections between them. ª 2009 The Author Journal Compilation ª 2009 Blackwell Publishing Ltd Geography Compass 3/6 (2009): 2084–2097, 10.1111/j.1749-8198.2009.00284.x Geopolitics of disease 2095 Short Biography Alan Ingram is a lecturer in Geography at University College London. He was educated and gained his PhD at the University of Cambridge. 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