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Health, Illness and Disease

A Political Ecology Perspective
Bikramaditya Kumar Choudhary

The conceptions of disease and its formulation under

different paradigms have made it clear that the
approach towards health and medicine has never been
completely detached from ecology. Health and disease
are thought to be the products of the interaction among
three key elements: the agent, the host, and the
environment. This paper is an attempt to develop an
approach that encompasses the concerns surrounding
an understanding of disease ecology and a patients
behaviour during treatment. Using the example of
tuberculosis patients put under DOTS, which disregards
the patients say in decision-making, it analyses the
implications for the larger health issue using the political
ecology approach.

he enjoyment of the highest attainable standard of

health as one of the fundamental rights of every human
being, without any distinction of race, religion, political
belief, or economic or social condition, gets a mention in the
preamble of the World Health Organization (WHO) (Walker
1955). Health, in a broader sense, is a state of complete
physical, social, and mental well-being ...not merely the absence of disease or infirmity (WHO 1968). Health, after all, is
simply an everyday word used to designate the intensity with
which individuals cope with their internal status and their
environmental conditions (Illich 1976: 16). In the dominant
tradition, health is reduced to a clinical concept, where the
body should be free from any infirmity or where disease is
absent. This functionalist perspective of illness is centred on
the role of the sick and the role of physicians, and according to
this, illness is legitimate as long as it is justified by the medical
job (Gallagher and Riska 2001). Interestingly, disease gets a
mention in both formulations of health, but its contextualisation is completely different in the two formulations.
A greater reliance on the notion of biological functions is
said to be the objective view of disease, which claims its
value-neutrality. Under this conception, statistical normality
and the concept of function became the basis for the
determination of disease. Boorse (1977) explained that a
disease is a type of internal state which is either an impairment of normal functional ability, that is, a reduction of one or
more functional abilities below typical efficiency, or a
limitation on functional ability caused by environmental
agents. Brown is critical of the increased biological interest
in defining disease, and notes that Boorses conception of
disease is a
...stipulative one and correspondingly his notion of disease will not
accord with common or general usages, but only with that of biologist
interested in physiology (Brown 1985: 320).

This paper is based on my doctoral work submitted to Jawaharlal Nehru

University. I am indebted to Atiya Habeeb Kidwai for her supervision.
My sincere thanks are due to the two anonymous referees, B S Butola,
Atul Sood, Vijay K Yadavendu, and Brahma Prakash for reading the
earlier draft and giving their inputs.
Bikramaditya Kumar Choudhary (bikramadityac@gmail.com) is with
the Centre for the Study of Regional Development, Jawaharlal Nehru
University, New Delhi.

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The concept of disease and health as a biological complete

was further challenged, and it was argued that a disease could
be considered a type of statistical variation in the history of
the organism, but variations need to be specified, as every
variation cannot be called disease (Brown 1985). This contestation brought a cultural element into the definition of disease,
along with the environmental agent. For example, impairment of the reproductive ability and homosexuality were considered diseases, while the Chinese did not consider the bound
feet of upper-class women a disease, in spite of their suffering
from pain (Kendell 1975).
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In due course, it was recognised that merely undesirable

physical conditions may not be considered disease. Engelhardt
(1975) argued that the conception of disease acts not only
to describe and explain, but also to enjoin to action; it is a
normative concept which says what ought not to be. As such,
the concept incorporates the criteria of evaluation, and delineates and establishes social relations, such as being sick or
being a physician (ibid).
A philosophical approach admits that disease is not only a
physical state or process of an organism, but also that which is
undesirable, disvalued or bad. It means that disease is a state
which is defined normatively, and therefore is relative. Several
others also conceded that the concept of disease is related to
our value systems and social judgment (Foucault 1975; Illich
1976; Margolis 1976; Merskey 1986). Under this conception:
Disease is the aggregate of those conditions which judged by the prevailing culture are deemed painful or disabling and which at the same
time deviate from either the statistical norm or from some idealised
status (King 1954: 197).

Margolis (1976) moved further and posited that disease is

whatever is judged to be a disorder or a cause to disorder the
minimal integrity of body and mind relative to prudential
function.
There is no agreed definition of disease. Purely biological
definitions are inadequate, and even definitions that combine
biological and social aspects are not satisfactory. Each culture
has its own characteristic perception of disease (Illich 1976).
Diseases take their features from the physicians, who cast the
actors into one of the available roles (Garfinkel 1956). Most
commonly, what physicians treat or what people complain
about is disease, and it leaves people free to take leave from
work (Mechanic 1962). It is in the power of the physician to
declare people as sick.
Conception of Disease:
From Ecological to Biomedical Dominance

The term ecology has varied meanings and its connotations

have changed over time in the context of medicine and disease.
For about 2,000 years, the importance of environment and space
in relation to the occurrence and prevalence of diseases has been
recognised. As early as the fourth century bc, Hippocrates
tried to explain the association between various factors of
environment and the occurrence of disease. He argued:
Whoever wishes to investigate medicine properly should proceed thus:
in the first place to consider the seasons of the year and what effects
each of them produce (for they are not like, but differ much from
themselves in regard to their changes). Then the winds, the hot and
cold, especially such as are common to all countries, and then such as
are peculiar to each locality. We must also consider the qualities of
water, for they differ from one another in taste and weight, so also do
they differ much in their qualities. In the same manner, when one
comes to a city to which he is a stranger, he ought to consider its situation, how it lies to the winds and the rising of sun; for its influences is
not the same whether it lies to the north or south, to the rising or setting of the sun ... one should consider ... the mode in which the inhabitants live and what are their pursuits, whether they are fond of drinking and eating to excess and given to indolence or are fond of exercise
and labour (Howe 1963: 8; Lilienfeld 1993: 20-21).
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With the so-called victories, breakthroughs and remarkable advances in medicine, and the development of vaccination for the common communicable and infectious diseases,
the social and cultural ecology tradition was relegated to an
unimportant position in the medical profession. It was advocated that only physicians can diagnose the cause of disease
and prescribe a treatment. Each disease has specific and distinguishable features which are universal to the human species,
and diagnosis is to be based on the combination and severity
of these symptoms.
The rise of modern science challenged and eventually overthrew explanations in the tradition of Hippocrates (Buchanan
2000). Most members of the medical profession in the last two
decades of the 19th century (1880-1900) were primarily interested in treating their patients and improving their individual
health. The successful works of Louis Pasteur, Robert Koch,
and others in bacteriological research led to the conceptualisation of the Germ Theory of Disease. The change in determining the cause of disease, that is, from environment to the
agent, has often been called the first revolution in the field of
medicine and health (ibid). The emergence of the clinical perception of disease can be traced back to the development of
the science of quantification spearheaded by Newton and Descartes in mathematics and mechanics, leading to the foundation of a quantitative and geometric description of the material
world and of human beings (Bernal 1969).
Modern medicine had the magic bullet in the form of drugs
that could be shot into the body to kill or control all health disorders (Dubos 1959). Diseases were seen as natural (biological),
resulting from a single key mechanism that dominated all others
(Thomas 1977, 1988). McKeown called it Flexnerianism, which
assumed that ... a living organism could be regarded as a
machine which might be taken apart and reassembled if its
structure and functions are fully understood (1971: 29).
The discovery and development of immunisation, sterilisation,
and later antibiotics resulted in a reduction of the incidence of
death to some extent (Buchanan 2000; Meade and Erickson
2000). Health and medicine thus became concerned with
disease, and not with positive health or community medicine
or social medicine (Black 1968: 5). However, contradictory
arguments against the role of medicine and medical research
in reducing deaths were made during first two to three decades of the 20th century (Dubos 1959; Doyal 1979; Illich 1976;
McKinlay 1984; McKeown 1976). They argued that the decline
in deaths and infectious diseases should be attributed to the
rising standard of living of people rather than to the distribution
of vaccines and antibodies. McKeown (1976) was not wrong in
stating that the enormous increase in population and dramatic
improvement in health that humans have experienced over
the past two centuries owe more to the changes in broad
economic and social conditions than to specific medical
advances or public health initiatives.
The vociferous criticism of the pure biomedical tradition
brought back the ecological concept, this time with another
name epidemiological analyses. Epidemiological analyses
were associated with the ability to apply findings rather than
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only the scientific merits or nicety of the study, and argued

that it must be concerned with the knowledge of and application to the social, environmental and biological factors of the
population (Pearce 1999: s1016). Population research was
identified as fundamental by Pearce (ibid), on the ground that
it is important to use research methods that are appropriate
to the level at which interventions will eventually take place
(McKinlay 1993: 112). Attempts were made to draw an association between social characteristics and disease ecology.
The basis of analysis nevertheless remained the controlled
and uncontrolled experiments and techniques that could be
accepted for generalisation. Merely associating a relationship
between social characteristics, disease incidence and health
status could not fully explain the totality of existing relationships. The causal concept became important in the analysis of
disease, and this brought epidemiology close to the biomedical
concept, which is intrinsically a reductionist and mechanical
approach. Epidemiology became an inductive science and
attaches considerable importance to methodology. Micro-level
study through the dominant bottom-up approach is suspected
to be dangerous when the outcomes of such research are
used for population-level interventions, due to the nature of
population-level determinants (Pearce 1999).
Disease and Health:
Preventive Care to Distributive Justice

The population consideration in the field of health and medicine

has led to two simultaneous developments in terms of the emergence of new sub-disciplines: public health and the political
economy of health. Often, this classification is contradicted by
arguing that public health is nothing but studying the health of
the population through a political economy perspective. However, one clear distinction can be made between the two. While
public health primarily advocates preventive methods to the
population through measures like water supply and sanitation,
political economy of health primarily investigates the rationale
behind such provisions, and also tries to explain the differences
and discrimination at the level of availability.
The great sanitarians of Europe, like Snow, Farr, Chadwick,
and many others, carried out thorough investigations into the
incidence of disease, and came up with external causes like
improper sanitation and poverty as the causes of major
diseases. With such works, geography (the human-environment
relationship) again became an important tool in understanding
disease in the 19th century. Pattermanns cholera map of 1852
showed the varying proportion of deaths from cholera in London
during the 1832 outbreak, and mapped the afflicted districts.
He was quoted as arguing that to obtain a geographical
extent of the ravages of the disease...geographical delineation
is of the utmost value and even indispensable (Pattermann,
quoted in Howe 1968: 38). Finke, a German physician, had
already produced the first world map of the disease in 1792
(Barrett 2000). Jarcho identified about 36 scholars who
published maps of cholera between 1820 and 1836 (ibid).
With the publication of John Snows map of cholera in London
in September 1854 and its association with water pumps
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around, geography and ecology proved to be of vital relevance

to the study of disease (McLeod 2000). Later, Snows work and
his concept of the water pump that he showed through a map
came under criticism, on the ground that Snow himself was
suspicious about the role of contaminated water. Snow wrote
in his own work that he suspected that contaminated water
from the pump was spreading cholera in the area, but that
samples did not reveal the water to be particularly dirty
(Snow quoted in McLeod 2000: 930).
The role of natural and social ecology was considered
important in any plan to combat disease through preventive
measures. Public health, which was an engineering science
earlier, has become a medical science, and needs to be
transformed into a social science. This argument for the
transformation of public health into social science has its origin in two related developments, viz, the economic rationality of health and the instrumentality of health. Health had,
by the late 19th century, become an instrument of govermentality, and states wanted to ensure the implementation of
good health.
Besides, the recurrent incidence of communicable diseases
in different parts of the world was responsible for a loss of the
labour force. These ideas dominated the health strategies of
developed and developing countries for a few decades, although
developing countries could not implement these measures due
to their poor economic condition. In tune with the existing
debates on public health, medical practitioners in India, too,
brought forth the scope of preventive measures. J B Grant has
been quoted as saying:
Public health is the science and art of social utilisation of scientific
knowledge for medical protection by maintaining health, preventing
disease and curing disease through organised community efforts for
(a) the hygiene of the environment, (b) control of the community
infection, (c) the education of the individual in principles of public
hygiene, (d) the organisation of medical and nursing service for the
early diagnosis and preventive treatment of disease and (e) the development of social machinery which will ensure to every individual in
the community a standard of living adequate for the maintenance of
health (Grant, quoted in Kumar 2010: 268).

Economic justification of good health or a disease free

body has historically been the reason for advancements in the
field of health and medicine. As early as the 17th century,
William Petty attempted to quantify the value of human life
and expressed an individuals value in terms of that persons
contribution to national production. He argued in favour of
state intervention in healthcare to the extent of employing
doctor as a salaried worker (Straus 1975: 32), as it would not
have been in the interest of the state to leave physicians and
patients on their own (Ober 1977).
Similar arguments were advanced by Chadwick, a utilitarian,
who influenced public health legislation in the first half of the
19th century in Britain (Lee and Mills 1983: 12). Chadwick advocated that the treatment of human beings should at best be
considered an investment in human capital. He argued that
better sanitation was a good investment, and that prevention
of disease could offer greater benefits than the building of
hospitals to treat those diseases.
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However, one can find a distinction between the two positions

that led to the development of public health efforts. One was
the economic justification in favour of preventive efforts, which
were said to be more cost-effective than curative medicines.
The Keynesian conception of demand-side market acceleration
put health under the category of consumption artefacts, and
E P Thompsons conception of labour saw in investment in
health an effort towards buying labour peace.
It was this utilitarian view of the human body and its use as
labour that promoted the improvement in sanitation and living conditions, and the control of many diseases worldwide.
An aggregate estimate of the economic effects of malaria was
done in terms of output lost, even in the colonies. In India, a
detailed survey of five villages was conducted to investigate
the effect of malaria on labour supply and earnings (Russel
and Menon 1942). The human capital approach, that is, estimating the productive value of human life, was also incorporated in the economics of health. Throughout the 1940s and
1950s, attempts were made to analyse the economic cost of
disease. The medical institutions and the ideology of medicine
remained under the influence of the capitalist system, guaranteed
through state interventions.
Whatever the considerations behind these efforts, they
definitely contributed towards an improvement in the living
condition of the population, including that of common people,
during the first half of the 20th century in the West, and in the
second half throughout developing countries. The situation
changed under the influence of Reaganism and Thatcherism
during the 1980s, with the withdrawal of state finance from
the social production of health and education, leaving them as
mere commodities.
The withdrawal of states which were protecting and promoting capitalist economy from health and education was
not unexpected. The state, as a configuration of public institutions and their relationships, has the prime objective of reproducing an economic system based on the private ownership of
the means of production. In this conception, the primary role
of the state is to establish the conditions under which the economic system could survive and flourish (Navarro 1977). The
capitalists as a class let the state invest in anything, up to the
point that it remained favourable to the production process,
either through accelerating production (by creating infrastructure) or buying labour peace. For example, when chronic
accumulation and overproduction resulted in the devaluation
of consumption items and affected built environments, they
withdrew from the housing sector.
The Contesting Domains

Different kinds of existing dualisms within the intellectual discourse are evident from the preceding discussion. Two distinctive approaches regarding the conception of health and disease
can be clearly identified: the first is concerned with the environment in which people live and/or the ecology of germs. The
second is related to the economic condition of society, which
determines the combative measures available or accessible to
certain people or groups.
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The two major traditions in the study of disease and health,

viz, disease ecology and health services research, have been
mutually exclusive streams of work. The gap between these
two traditions increased, despite the introduction of the
Marxist political economy approach in the late 1960s. The other
dualism in the study of disease and health has been biological
versus ecological. While the first involves interventions based
on pathological research, the second includes environmental
issues. In terms of methodology, it can be grouped under (a) methodological individualism, and (b) methodological holism.
Doyal (1979) argues that it is always the individual who becomes sick, and it is not the social, economic or environment
factors that make her/him sick. Stark similarly argues:
Disease is understood as a failure in and of the individual, an isolatable thing that attacks the physical machine more or less arbitrarily
from outside preventing it from fulfilling its essential responsibilities.
Both bourgeoisie epidemiology and medical ecology ...Consider society only as a relatively passive medium through which germs pass en
route to the individual (Stark 1977: v).

The recent recognition of individual-specific cognitive responses to particular events (symbolic interaction perspective)
in the analysis of illness has added a new dimension to the
meaning of illness (Fife 1994). It has highlighted an individuals
relationship to her/his social world during illness, and an individuals response to particular situations during illness, as well
as to the illness itself. This vision of scientific medicine, which
itself has been labelled subjective,1 led to a victory of the individualistic-mechanistic view over that of the environmentaliststructuralist an approach advocated by Virchow (Navarro
1977; Turshen 1977). This all-pervasive individualism has been
described as:
The human world consisted of self-contained individual atoms with
certain built-in passions and drives, each seeking above all to maximise his satisfactions and minimise his dissatisfactions....In the course
of pursuing this self-interest, each individual in the anarchy of equal
competitors found it advantageous or unavoidable to enter into certain relations with other individuals, and this complex of useful
arrangements which were often expressed in the frankly commercial terminology of contract constituted society and social or political groups (Hobsbawm 1962: 729).

Individualism, in this respect, is a political or economic theory that asserts the rights of the individual against those of the
community. This approach brings us close to methodological
individualism. Although this theory apparently seems more
appropriate as it takes into account various levels of stress and
responses at the individual level, in most cases it ultimately
ends up in victim blaming (Pedersen 1996). Epidemiologists
efforts to rediscover the population perspective and move
towards eco-epidemiology through a set of generic methods
and multilevel analysis, rather than the repeated use of
individual risk factors, brought them closer to methodological
holism.2 In this tradition, in the past, a person was thought to
be a unified whole, and illness and disease were regarded as a
product of imbalances in the general harmony between the
individual and the world, since life itself was viewed in
cosmological terms; spiritual dimensions were not excluded
from the realm of health.
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Various conceptions of disease, and its formulation under

different paradigms, namely, disease ecology, biomedical traditions, and public health practices, have made it clear that
approaches towards health and medicine have never been
completely detached from ecology. This conception of disease
continued in all disciplines of knowledge. It is now established
that the population, society, and physical and biological environments are in dynamic equilibrium. This existing relationship has remained an important principle of disease ecology.
With any change in the existing pattern or in the existing relationship, there ought to be a new disease, or a new rate of
growth or decline in existing disease. This argument was
substantiated in the study on infectious diseases, and Mayer
articulated:
...the human-environment relationship, if disbursed enough by major
changes in land-use, migration, population pressure, or other stressors can show significant maladaptation as manifested by the appearance or diffusion of new disease (Mayer 2000: 937).

Proponents of the ecological approach were divided into

two groups. One group overemphasised a systemic approach,
while the other group opposed it. Robert McIntosh argued:
Ecologists are in a period of retrenchment, soul searching, extraordinary introspection...This follows on nearly three decades of heady belief on the part of some ecologist ...that communities are structured in
an orderly predictable manner, and of others that information theory,
systems analysis, and mathematical models would transform ecology
into a hard science (McIntosh 1987: 321).

Division of a similar kind was highlighted in the conception

of new ecology. It advocated a significant reorientation that
had occurred in the field of biological ecology on the one hand,
and emphasised the need for an analysis of non-predictable
behaviour of communities on the other (Zimmerer 1994). In
the disease ecology perspective, scholars have frequently
adopted the first kind of ecological conception, that is, functional and structural, rather than historical. They considered
it important to explain the pattern of disease rather than the
behaviour of an individual, which is determined by various
factors and is difficult to generalise. This viewpoint placed the
disease ecology paradigm closer to biological sciences than to
geographical explanations.
Disease ecology has often been seen as one discipline that
concentrates on the biological aspects of disease. Disease ecologists are much more concerned with the biological aspect
and epidemiology rather than with geography, because they
attempt to study the specific etiology of disease in the context
of the agent and its growth/maturity in the host in any specific
environment, and not the spatial variation that is culturally
constructed (Barrett 1993; Learmonth 1988).
Marxist political economy, too, has a deterministic approach
while offering the best scientific explanation of social hierarchy
in the form of class structure with regard to the availability
of healthcare facilities or the occurrence of certain diseases
in different localities. The concept of class as the twosector model, exploiter and exploited, entrepreneurs and
workers, bourgeois and proletariat came under a cloud with
the introduction of hegemonic and subterranean power
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(Gramsci 1996; Foucault 1989).3 There are smaller power

centres rather than power blocs at different levels of society,
which make these interventions problematic. Marxs brand of
socialism has been accused of ignoring the fragility of the natural environment and its relationship with stratified society,
as it believed in the existence of a freely available environment
that cost people nothing.4
These contested views are similar in that they are all based
on broad generalisations. The population perspective on disease and health tries to generalise the conditions prevailing in
a particular society and outside the human body, but which
nevertheless affect the well-being of the body and mind and
their interaction. The individualistic perspective, on the other
hand, generalises the functioning of the human body and
takes a closer view of the body, functioning of the cells, and
the effects of germs on cells, rather than the factors that
led the germ to enter the human body. However, it does so at
the level of gross generalisation and a universalised principle
concerning all human bodies.
Political Ecology Approach: An Alternative to Universalism

Alternatives always emerge out of dissatisfaction with the

generalisation and systematisation of earlier approaches. The
inadequacy of existing social orders to attain the ideal equality
in society and the resultant disenchantment with the Left led
concerned people to search for an alternative paradigm, which
later became crystallised as Political Ecology. The main objective
of this approach was similar to the Marxist political economy
approach; however, there was an obvious disillusionment with
the earlier approach, as Alain Lipietz puts it:
...From reformulation to renewal and revolutions within revolution, it
has to be admitted that socialism is not the earthly manifestation of
this dream which humanity has in its head and which only has to be
experienced (and applied) for the world to posses it in reality. Human
societies are more complex than socialism had believed. The dream of
utopian communists in the 19th century, of a community of individuals in
free association, delivered from the division of labour, fishermen in
the morning, artesian in the afternoon, and literary critics in the
evening this dream will always be mine as well (Lipietz 1995: x).

Political ecology clearly implies an opposition to existing

approaches, which remain entrenched in generalisations. It
is a critique of the order of existing things, but remains largely
rooted in political economy. Mayer (2000) holds that most
political ecologists have used critical, and usually Marxist,
concepts of political economy, but have not adhered to the
concept as given by Marx. Political economy believes in the
consistency of historical processes and favours generalisation
and universalisation based on quantification. It believes that
the place of the individual in society is determined by forces of
production and the social relations of production.
Political ecology, like Maoist versions of Marxism, questions the primacy of productive forces and subordinates them
to social relationships, and to a vision of the world that
inspires this relationship (Lipietz 1995). Access to, and utilisation of, healthcare are determined primarily by social relations, and access to the knowledge available. The application
of political ecology approach (PEA) to health and disease
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would not accept a binary division of society into capitalist

and proletariat. Rather, it analyses power blocks as well as
bottlenecks at different levels of operation across society,
spread over different geographies.
PEA is often defined as an approach to but far from a
coherent theory of the complex metabolism between nature
and society. The basis for such a definition has been two geographical monographs (Blaikie 1985; Blaikie and Brookfield
1987), which are said to provide the theoretical and intellectual foundations for the formulation of PEA (Johnston 2000;
Walker 2005). Blaikie and Brookfield hold that
The phrase political ecology combines the concerns of ecology and a
broadly defined political economy. Together this encompasses the constantly shifting dialectic between society and land-based resources and
also within classes and groups within society itself (1987: 17).

The concerns of ecology and political economy provided the

philosophical base for political ecology as an approach.
Ecology in PEA adopts different meanings from that in natural
science. The ecological concerns of political ecology started
with one study related to land degradation and soil erosion in
the 1980s. However, political ecology is more than James
Lovelocks (1988) cult of Gaia, and has borrowed methods
and inspiration from the Red. The core of political ecology is
not the environment, but a complex totality consisting of a
triangle: humankind, its activity and nature; nature under
threat and transformed by human activity; and nature that is
both the matrix and the basis of this activity (Lipietz 1995).
Studies under PEA were a confluence of three theoretical
approaches: cultural ecology, ecological anthropology, and
Marxist-inspired political economy. According to Escobar
(1999), an important goal of political ecology is to understand
and participate in an ensemble of forces linking social change,
the environment and development. Peet and Watts (1996)
analysed political ecology as an approach to social analysis,
and argued that this political economy-driven political ecology
absorbs other elements, particularly the post-structuralist
analyses of knowledge, institutions, development, and social
movements. Walker (2005: 74) similarly argues:
Early writings in political ecology focused on unequal power relations,
conflict and cultural modernisation under a global capitalist political
economy as key forces in reshaping and destabilising human interactions with the physical environment.

The inclusion of cultural and social practices in an understanding of physical and disease ecology has led critics to argue
that the new focus of political ecology is on politics, and that
the role of ecology has been marginalised. Notable among these
critics are Pete Vadya and Brad Walters (1999: 168) who argued:
Some political ecologists do not even deal with literally the influence
of politics in effecting environmental change but rather deal only with
politics, albeit politics somehow related to the environment. Indeed, it may
not be an exaggeration to say that overreaction to ecology without
politics of three decades ago is resulting in a politics without ecology.

However, not including questions of biophysical ecology or

not deeply investigating environmental change does not make
a study fall outside the ambit of political ecology. Political
ecology is not primarily concerned with the environment
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per se, but with three interrelated issues of humankind, its

attitude and actions towards the environment, and the
actual environment. Political ecology distrusts any growth
of productive forces (where humanity is dominant over nature),
and asserts that a different relationship among human beings
would mean a better relationship between humans and nature.
Another key issue within political ecology is the exploration of
multi-level connections as against a dualism between global
and local phenomena, not only in environmental functions but
also in decision-making and hierarchies of power.
Political ecology began as a rejection not only of economic
liberalism which, while established longer, was clearly based
on the same premise but also of the kind of socialism that
ignores the unmindful exploitation of the environment and the
oppression of women (Lipietz 1995). Thus, political ecology as
an approach favours an inclusive study that takes into account
the ecological, social and political trajectories of human life,
along with questions of class, gender and power relations. This
new approach is concerned with tracing the genealogy of narratives concerning the environment, identifying the power relations supported by such narratives, and asserting the consequences of hegemony over and within these narratives for economic and social development, and particularly for constraining possibilities for self-determination (Adger et al 2001).
Political Ecology Approach to Disease

Existing theories in the field of health and medicine were progressively considered inadequate to explain the causes behind
the increasing discrimination against certain sections of society,
especially in the third world. On the one hand, poor people
were the main victims of deteriorating environmental conditions
and the resultant diseases emanating from polluted surroundings,
for which they were not responsible. On the other hand, corporatisation of health services was on the rise in the first world
under the influence of Margaret Thatcher and Ronald Reagan,
and economic policies in the socialist world, especially in Russia and China, were undergoing certain fundamental changes.
The problem was more acute in third world countries, where
states started withdrawing from healthcare. The impetus for
such acts was drawn from the writings that established the
failure of state in providing healthcare to people, citing
bureaucratic and administrative inefficiencies (Peters and
Muraleedharan 2008). Critics rightly voiced their concern for
the poor in the wake of health being turned into a commodity
liable to market rules and consumer behaviour, rather than
being considered a fundamental human right (Meier and Fox
2008). Nancy Birdsall, in her article on good heath and good
government, holds that
such politically successful leaders ...have espoused an approach to government that says simply, less is better. In the same period some highly
planned socialist economies, including Hungary, China and Soviet Union,
have sought ways to imitate, if not duplicate, the apparent advantages
of so-called market-led economies ...(Birdsall 1989: 89; emphasis mine).

Simultaneous developments were noticed in other spheres of

public life under the tag of globalisation, which was considered
necessary for economic growth. The WHO, a nodal agency that
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promises to ensure good health for all, states in almost so

many words that the only choice before governments is to join
in and facilitate the process, to open up their countries to
globalisation, since any resistance to doing so will be penalised.
The obvious effects of globalisation in the health sector
included further and accelerated withdrawal of the state from
welfare schemes, so that internationally committed reduction
in public deficits could be achieved (Navarro 1999).
These developments made people lose faith in the adequacy
of even the political economy approach, and a need was felt for
a new perspective to explain the existing situation in the
health sector. A response to this was the political ecology
approach, which tries to combine the concerns of ecology and
a broadly defined political economy. Both ecology and political
economy had earlier been used to study the distribution,
pattern and inequality of the healthcare delivery system. A host
of scholars have discussed the role of the state, public policy
and political economy behind the medical advancements and
charity-based medical programmes (Blane 1996; McKeown 1976;
McKinlay 1984; Navarro 1977, 1998; Marmot and Wilkinson
1999; Wilkinson 1986).
The political economy approach, as discussed earlier, ignored an individuals inability to find the strength to adopt advised coping techniques, while the ecological approach remained
embedded in host and agent (May 1958, 1960; Meade 1976,
1977). The power structure at the individual and local levels
was almost ignored in these intellectual traditions, and both
approaches claimed an unstated supremacy in solving the
rampant problem of ill-health across the world.
The mutual embeddedness of these hierarchies precludes a
simplistic approach to the study of disease and health. The PEA
builds on analyses of identities and differences, and of pluralities of meanings in relation to the multiple sites of environmental struggle and change (Rocheleau et al 1996). The concept of disease, medicine and health is as important for this
approach as the concept of power, state and class, which shape
the physical and social environment (Robbins 2004).
The PEA to the study of health, disease, and related problems
has two differences with earlier practices: first, it tries to
intertwine disease ecology and health services research, and
second, it negates the culture of generalisation. Generalisation
involves scientific techniques such as observation, experimentation and generalisation, and avoids uniqueness or facts
that cannot be generalised. Nevertheless, health and disease
are as individual as they are universal, because all evidence
from the field suggests that humans respond in multiple ways
to the same treatment regimen for the same disease. This is
true for both communicable and non-communicable diseases.
Political Ecology Approach to Tuberculosis
Communicable diseases still form the largest cause of morbidity
and untimely deaths, and the fight against them needs to be
continuous if we are to achieve the objective of health for all.
As noted by Farmer:
However secure and well-regulated civilised life may become, bacteria,
protozoa, viruses, infected fleas, lice, ticks, mosquitoes, and bedbugs

66

will always lurk in the shadow ready to pounce when neglect, poverty,
famine, or war lets down the defences, and even in normal times
they prey on the weak, the very young and very old, living along with
us, in mysterious obscurity waiting their opportunities (2001: 37;
emphasis added).

Tuberculosis remains one of the major public health menaces

and the single largest cause of untimely deaths in India, despite regular state interventions (which are primarily medical)
through preventive and curative measures. The National Tuberculosis Control Programme (NTCP) was marred by a low
completion rate of 30%, coupled with a shortage of drugs, poor
quality of microscopy, and so on. The review and the changed
global approach to tuberculosis resulted in a Revised National
Tuberculosis Control Programme (RNTCP), with an emphasis
on higher cure rates through the administration of Directly
Observed Treatment, Short-Course (DOTS).
The experience in Delhi suggests that the ongoing antituberculosis campaign, that is, RNTCP, is target-driven; during
the survey, it was found that in the eagerness to pursue the
target (achieving a higher cure rate), patients who were not
likely to come to the DOTS centre were not enrolled. In this
category were the homeless, who had no address to which they
could be traced. The poor migrants who needed the treatment
most were the ones left out to maintain the high completion
rate. It makes little sense to achieve a cure rate of 85% in some
patients, at the cost of leaving out many others.
The study in New York City shows that only 40% of the
patients, especially those who are probably non-compliant,
receive treatment under DOTS (Bradford et al 1996). In contrast,
in Delhi, a patient is called for chemotherapy only if s/he is considered likely to be compliant. RNTCP remained mired in problems
like poor coverage, poor quality of sputum examination, poor
record-keeping, lack of involvement of healthcare providers,
poor coordination, use of non-standard treatment regimens,
and patients difficulties in complying with the DOTS regimen.
However, rather than addressing the structural reasons for
the failure of NTCP, during the Eighth Five-Year Plan, the state,
without much discussions on relevant problems, opted for universal coverage under RNTCP, envisaging a 50% reduction in
mortality from tuberculosis (National Tuberculosis Report 2012).
Field evidence from Delhi further indicates two evolving but
dangerous trends in the universalising of tuberculosis treatment: first, the increasing cases of a multi-drug resistant (MDR)
variant of tuberculosis amongst patients who completed DOTS,
and second, liver diseases arising from the DOTS regimen.5
DOTS, with complete disregard to alternative possibilities,
pitched for the extensive use of available drugs, which had
already lost their effectiveness. The argument that missing
doses are the prime cause of MDR, along with poor quality
drugs and wrong treatment methods, is faulty, as an abundant
supply of drugs, universal singular treatment, and complete
regimen under clinical conditions could not prevent MDR
either. A significant proportion of tuberculosis patients were
found to be suffering from MDR (Choudhary 2008). Further,
the psychological costs of having a disease that remains taboo
in India are left to uncertain clinical remedies.
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Tuberculosis patients in Delhi represent a segment of the

global burden of disease, and reflect the universalised treatment
regimes that cater more to the supply-side problem of the global
pharmaceutical industry than to a need-based approach to
contain tuberculosis. The growing critical literature on health,
development, and patients perceptions of treatment has led to
a better understanding of the prevailing scenario in a world
with finite resources and fractured communities (Choudhary
2013). Class comparisons of mortality rates and morbidity incidence are periodically carried out: the political economy perspective to health and disease has led to a proliferation of studies indicating that an individuals life chances and lifestyle can
be intimately related to the economic and occupational strata
that person occupies in society. However, the relationship between individual behaviour and health remains confined to
quantitative generalisations, like drinking, smoking, etc.
An inevitable move towards the incorporation of environmental factors in epidemiological studies and in the analysis of
the prevalence of infectious diseases became imperative. The
environment differs for each individual and community, as
their access to the environment is determined by the relative
power they have at their disposal. Therefore, the new perspective PEA incorporates factors like power hierarchies, role
of the state and policy, role of culture and individual responses
towards the disease, and combative measures in the existing
disease ecology tradition.
The most important theme that recurs in political ecology
analysis includes the need to set a problem or phenomenon in
its broader social and economic context, and the need to relate
both the phenomenon and its socio-economic context to a variety of scales, ranging from local to global. Mayer (1996) considered the political ecology of disease a promising, even if as yet
underdeveloped, approach to understanding disease dynamics.
PEA is potentially useful in the social interpretation of emerging
and resurgent disease, as it emphasises unintended human and
natural consequences of individual, corporate and governmental projects, and demonstrates aptly that disease has its humanmade components, as well as its natural components.
Summing Up
An increase in various diseases in different parts of the world,
and the existing magnitude of malnutrition and its consequences, have shattered the preoccupation of health professionals with the germ theory of disease, as well as that of

Notes
1 Science is subjective a body of scientific
knowledge such as medicine is the systematic
approximation of reality, but is neither equivalent to nor the same as reality itself (for details,
see Turshen 1977: 45).
2 In methodological holism (or collectivistically
oriented social philosophy), the focus is primarily
on social constellations (age, sex, social class, and
race/ethnicity) or places and social positions in
society, and how these are decided. This strand
advocates the go outside the body approach to
develop an alternative social and environmental
perspective on health, where socio-economic,
cultural and political factors are included in the
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development economists with the political economy approach

to the healthcare distribution system based on large-scale
generalisation. Health and illness are the outcomes of existing multidimensional and complex people-environment relations. Obviously, the definition of health and disease has been
changing with changes in the paradigms in which they are
analysed and transformed. In recent times, two divergent
paradigms have been existing simultaneously the dominant
paradigm considers disease or illness a disturbance, an exaggeration, a diminution, or cessation of a corresponding normal
function of the body.
The proponents of the less-acknowledged paradigm consider health akin to adaptability. Under this paradigm, the
concept of disease gets transformed from a biological entity to
a measure of the maladaptive interactions among the familiar
triad of population, environment and culture, defined as
Political Ecology. Biological reductionism, instrumentalism,
and atomisation or positivism widen the gap between patients,
physicians, and their environments. Another simultaneous
development albeit not parallel to the dominant biomedical
tradition in the field of health and medicine was the return
of the concept of the whole person, which objects to the
reduction of human beings from a molar to a molecular
identity, and questions the practice of victim blaming. One
can only be made responsible for ones surroundings or
environment if s/he has had a share in the decision-making
processes.
Political ecology, using this conceptualisation, stresses three
basic concerns: Solidarity, Autonomy and Responsibility.
PEA examines the historical role of economic systems, science,
language and discourse, ideology, gender, property systems,
social movements and resistance, and the everyday politics of
the community as it aims to address the issue of solidarity.
The responsibility concern of health and disease is addressed
under PEA by taking into account the nature of the everyday
politics of the household in shaping human relationships
with nature, which determine the occurrence of disease,
treatment-seeking behaviour and coping mechanisms. Autonomy
concerns are dealt with in PEA through the use of the patients
perception of coping methods and the treatment regimen.
The PEA to disease accepts the role played by these factors
in shaping the map of disease in a particular locality and
society, and expects to provide a better explanation for
prevailing situations.

analysis of diseases and death in a society. For

details, see Yadavendu (2013).
3 Gramsci developed the concept of hegemony to
explain why the exploited classes accept the existing social order, while Marxist theory suggests
that workers would not accept the exploitative
social relations. Gramsci further suggested that
the dominance of a class depends not only on
the repressive machinery of the state, but also
on the fact that a prevailing mode of thinking
and thought process shields the existing social
order (for details, see Gramsci 1996). Foucault,
while discussing the concept of power for discipline, departs significantly from the traditional
liberal and Marxist understanding of power.
vol xlix no 45

Discipline, which increases the capabilities and

efficiency of human beings, also ensures their
controllability. Such control is possible with the
spread of disciplinary power. This kind of power
has been linked with certain norms and standards
that define normal behaviour for humans. Such an
explanation of power is interwoven with forms
of knowledge, and is subterranean rather than
naked. Consequently, the onus lies on psychologists to decide what could be considered normal
behaviour for human beings (Foucault 1989).
4 It may not be wise to accept this argument in
totality; as Marxs early writings (1964) suggest,
we know only one science, the science of history.
History can be viewed from two sides: it can be

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divided into the history of nature and the history
of man. These two sides, however, are not to be
seen as independent entities, and the humannature relation is explained in different ways.
5 The problems with DOTS are wide-ranging. They
include a loss of self-respect, loss of labour days
on alternate days, a sense of complete mistrust
in themselves, apart from clinical deficiencies.
For details, see Choudhary (2008).

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