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Landscapes of Care

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Landscapes of care
Christine Milligan and Janine Wiles
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Article
Progress in Human Geography
34(6) 736–754
Landscapes of care ª The Author(s) 2010
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10.1177/0309132510364556
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Christine Milligan
Lancaster University, UK

Janine Wiles
The University of Auckland, New Zealand

Abstract
The term ‘landscapes of care’ has increasingly taken hold in the lexicon of health geography. As the complex
social, embodied and organizational spatialities that emerge from and through relationships of care,
landscapes of care open up spaces that enable us to unpack how differing bodies of geographical work
might be thought of in relationship to each other. Specifically, we explore the relation between
‘proximity’ and ‘distance’ and caring for and about. In doing so, we seek to disrupt notions of proximity as
straightforward geographical closeness, maintaining that even at a physical distance care can be socially
and emotionally proximate.

Keywords
caring about, caring for, distance, landscapes of care, proximity

I Introduction usefulness as a framework for unpacking the

complex relationships between people, places
Care and care relationships are located in,
and care.
shaped by, and shape particular spaces and
In this paper we attempt to map out what such
places that stretch from the local to the global.
a framework might look like. In doing so we
Geographers thus have the potential to make a
engage with a wide body of work on care within
crucial contribution to interdisciplinary debates
human geography, teasing out the interplay
around care. A significant number of geogra-
between those socio-economic, structural, and
phers have engaged with ideas around care, from
temporal processes that shape the experiences
a range of discourses and perspectives. This is
and practices of care at various spatial sites and
important for advancing the subject but it is also
scales, from the personal and private through to
important to explore the threads that connect
public settings, and from local to regional and
these discussions. In our view this undertaking
national levels, and beyond. First, we outline
will facilitate the visibility of this geographical
what we understand by care and landscapes of
project beyond the discipline. We believe that
care. We then critically discuss issues of
a useful way of capturing the complex spatial-
ities that care and care relationships entail is
through ‘landscapes of care’, a term that has seen
Corresponding author:
growing popularity in recent years. Too often, Christine Milligan, Division of Health Research, Lancaster
however, it is used as a rather loose spatial meta- University, Bailrigg, Lancaster LA1 4YT, UK
phor with limited attention paid to its potential Email: c.milligan@lancaster.ac.uk

736
Milligan and Wiles
proximity and distance within landscapes of care
and how they relate to questions of caring for
and caring about. Third, we consider work
around geographies of care and responsibility
and how these may be framed within debates
around ‘care-ful’ and compassionate geogra-
phies. In the final section we reflect on the con-
tribution that one subdiscipline, health
geography, is making to landscapes of care
through an illumination of the changing topogra-
phies and spatialities of care. We seek to draw on
and further current geographical debate around
care and suggest how this rapidly growing area
of interest might be further developed.
II Landscapes of care
From cradle to grave, we give and receive care.
It enriches our lives and bolsters our ability to
function successfully. Quite simply, without care
we would fail to thrive. Yet, despite its centrality
to all aspects of our lives, it is remarkable how
marginalized care is (Lawson, 2007). Hence,
before engaging with landscapes of care, we dis-
cuss what we mean when we talk about care.
1 Defining care
Care is the provision of practical or emotional
support. Critically, as geographers we must con-
sider whether we should even use the terms care
and care-giving. Some carers see all caring as
‘work’; others strongly resist such a definition,
seeing care less as work and more as ‘something
you just do’ as part of a reciprocal and loving
relationship (Rose and Bruce, 1995). For others
the term ‘care’ has become imbued with patern-
alism reinforcing notions of dependency (eg,
Tronto, 1993; Oliver, 1998; Sevenhuijsen,
1998; Shakespeare, 2006). Within disability
studies, commentators have argued that termi-
nology should move away from care toward
ideas of independence and personal support
(Oliver, 1998; Shakespeare, 2006; Thomas,
2007; Kröger, 2009). While this argument may
be justified, such debates also arise as a
737
consequence of how we think about care itself.
There is a tendency, for example, to view care
as a unidirectional activity (ie, from active
care-giver to passive recipient) but, as Fine and
Glendinning (2005) point out, it involves reci-
procal dependence in which both recipients and
providers are involved in the coproduction of
care. Care entails a complex network of actors
and actions involving multidirectional flows and
connections (Tronto, 1993; Milligan, 2000;
Wiles, 2003a; 2003b). It is ‘necessarily rela-
tional’ in that it involves ongoing responsibility
and commitment to an object (or subject) of care
(Tronto, 1989: 282).
Hence it is probably more useful to think of
care in terms of interdependency, reciprocity
and multidirectionality (Wenger, 1987; Tronto,
1987; Kittay, 2001; Watson et al., 2004). Multi-
directionality can occur in several overlapping
senses: (1) care often involves networks rather
than dyads; (2) even within dyadic relationships
different kinds of care, including physical and
affective, are frequently exchanged; (3) care can
be expressed as delayed or extended reciprocity
(eg, care for an ageing parent may reflect reci-
procity for care received in childhood); and (4)
care providers frequently derive significant ben-
efits such as new perspective, a sense of pride or
satisfaction, learning new skills or developing a
vocation, a sense of power, or alleviation of
guilt. Many of the care-workers in Meintel
et al.’s (2006) study expressed a ‘love’ of their
work and describe it as a vocation rather than a
job. Reflecting on the instability of the power
relationships between paid care-givers and
care-recipients, Kittay (2001) further pointed out
that while dependency is frequently cast in terms
of the care-recipient, the low pay received for
care-work means that paid care-workers are fre-
quently drawn from groups who are already rel-
atively powerless and occupy a lower social
status than that of the person they care for. Para-
doxically this can lead to interlaced frameworks
of power and powerlessness where the care-
recipient may be dependent on the care-worker
737
738
to meet their fundamental needs, but the
care-worker may also be vulnerable not only to
the actions of the care-recipient but to the
interests of their employer as well (Kittay,
2001: 561).
Caring is also frequently emotional. Held
(2006) and Kittay (2001) both maintain that an
affective component is critical to good care.
While Twigg and Atkin (1994: 8) do not go quite
this far, they do suggest that ‘caring relations if
not defined by love, are frequently associated
with and energized by it, although in more com-
plex and ambiguous ways than the normative
picture might suggest’. Care-givers do not sim-
ply do things for people; they also support them
with encouragement, personal attention, and
communication in ways that endorse a mutual
sense of identity and self-worth. By rethinking
how care is conceptualized, some of these dis-
empowering narratives about care and depen-
dency lose their authority.
How care is understood and experienced is
shaped by social and political-economic con-
texts operating at the level of the individual or
wider society, and in public or private spheres
(Wiles and Rosenberg, 2003; Milligan, 2009).
The decision to give care, and who provides that
care, can be based on a wide range of factors
including need, close kinship bonds, norms and
values around gender and kinship, ability to
cope, proximity, labour and employment rela-
tions, the availability and cost of alternative
sources of support, and financial and opportunity
costs. Thus any attempt to understand care
means that we need to consider not just the
care-giver or care-recipient but all those
involved in the care relationship. Critically, the
nature, extent and form of these relationships are
affected by where they take place. For geogra-
phers, then, care involves not just interpersonal
relations but also people-place relationships. It
is important to recognize ‘the thoroughly spatial
ways care [is] structured and practiced’, empha-
sizing the intricacy and richness of that spatiality
(Brown, 2003: 849) and the relationship
738
Progress in Human Geography 34(6)
between place and well-being (Poland et al.,
2005; Wiles, 2005; Wiles et al., 2009).
2 Defining landscapes of care
‘Landscapes of care’ echoes and builds on
earlier geographical work around deinstitutiona-
lization and those ‘landscapes of despair’ cre-
ated by restructuring processes (Dear and
Wolch, 1987; Gleeson and Kearns, 2001). It also
builds on the healing properties and cultural geo-
graphies intrinsic to ‘therapeutic landscapes’
(Gesler, 1992; Williams, 2007). In doing so,
geographical work has begun to articulate care
through the differing, and sometimes surprising,
social spaces that enable caring interactions
(Conradson, 2003a; 2008a); as individual
space-time trajectories through varied social
landscapes of care, care-giving roles, employ-
ment and social policies, and gendered and gen-
erational expectations of care and work (McKie
et al., 2002); through the entanglements of
exclusion and inclusion, dependency and inde-
pendency that can manifest within and across
formal and informal spaces of care (Power,
2009); and through the emotional landscapes
that underpin care and care interactions (Brown,
2003; Milligan, 2005; Milligan et al., 2005).
Such landscapes can encompass the institu-
tional, the domestic, the familial, the commu-
nity, the public, the voluntary and the private
as well as transitions within and between them
(see, for example, work by Cartier, 2003;
Skinner and Rosenberg, 2005; Carolan et al.,
2006; Skinner et al., 2008).
Engaging with landscapes of care as an analy-
tical framework requires an understanding of
macro-level governance or social arrangements
that can operate at either (or both) the national
or international scales as well as the interperso-
nal. This may include such issues as local,
national and international migration patterns;
cross-national work arrangements; changing
national and international policies; and ideologi-
cal beliefs about the arrangements of care – for
Milligan and Wiles
example, sociocultural beliefs, political values
and other conditions that affect the (re)allocation
and (re)distribution of public and private funds
and resources for the provision of care; the
restructuring and centralization or decentraliza-
tion of responsibility and decision-making for
care (eg, Moon and Brown, 2000); and the social
norms and discourses that shape family and per-
sonal decisions about care provision. At the
regional or even international scale, policies and
place characteristics impact on the distribution,
availability, migratory flows, and composition
of health and social care workforces (Farmer
et al., 2003; Meghani and Eckenwiler, 2009;
Connell, 2009).
Other exemplars, however, are experienced
as micro-landscapes of care; such as the hospital
room, the nursery or the home, including the
reorganization of specific rooms, social arrange-
ments and work practices within and beyond the
home to accommodate the performance and
paraphernalia of care as well as the shifting
power relations they imply (England, 2000;
Williams, 2002; Cartier, 2003; Radley and
Taylor, 2003; Curtis et al., 2007). Wiles’s
(2003a; 2003b) work on the experience of caring
at home shows how the home as a context for
care shapes both the care itself (for example, the
availability of formal support to family care-
givers) and has a huge impact on how people
perceive and experience their homes. Dyck’s
(1995a; 1995b; 1998) work around chronic
illness and disability, migrants, place-making
and home, self-care, care services, and long-
term care also illustrates how the relationships
between bodies, home spaces, and different
kinds of care actively [re]construct the experi-
ence and meaning of those spaces. Her more
recent collaborative work has addressed the
home as a ‘landscape of care’ in the context of
policies designed around long-term care in the
community. This work focuses on the experi-
ences of community-based health workers as
well as those receiving care at home (Dyck et
al., 2005). It illustrates how policies and values
739
constructed at a scale beyond the home not only
impact on the way caring spaces are produced,
but can also lead to clashes of values and mean-
ings of home (see also England, 2000; Angus et
al., 2005).
Landscapes of care are thus spatial manifesta-
tions of the interplay between the sociostructural
processes and structures that shape experiences
and practices of care. As examples of care set-
tings, hospitals, asylums, nursing homes, hos-
pices, day-care nurseries and homeless shelters
all form part of the physical and social fabric
of the places in which they are located (eg,
Wolch and Philo, 2000; Hanlon, 2001; Brown,
2003; Conradson, 2003b; Joseph et al., 2009).
So too do contemporary retirement ‘villages’
with hospitals attached or corporate offices ser-
ving as headquarters of mobile community-
based health professionals and others working
in the care industry (Laws, 1995; McHugh and
Larson-Keagy, 2005; Conradson, 2008b). Such
examples are all manifestations of particular
political and social arrangements for the
provision of care.
It is important to recognize, however, that
work on sociospatial dimensions of care extends
beyond the health domain. For example, other
aspects of care have involved the political work
of caring for places (Staeheli, 1994; 2003; Lake,
1994; Smith and Beazley, 2000). A small but
distinct body of work around human-animal
relationships of care has also emerged. Such
work focuses on the environmental politics of
human-animal relations; the shifting cultures of
care, control and commodification of animals;
and the need to re-establish networks of care
between humans and animals (see, for example,
Wolch, 1996; Michel, 1998; Emel et al., 2002).
Others have engaged with the sociospatial
dimensions of the care and service work required
to reproduce our lives, such as cooking, cleaning
and other domestic work (Preston et al., 2000;
McDowell, 2003). Childcare and the class and
gendered inequalities arising from economic and
social restructuring, employment and the
739
740
relative accessibility of childcare across space
are also examples of work in this vein (eg,
Fincher, 1991; D. Rose, 1993; England, 1996;
Holloway, 1998; Dyck, 1989; McDowell et al.,
2006; Dunkley, 2009). Pratt’s (1997) work on
the discursive construction of cultural stereo-
types of nannies further reveals some of the
anxieties around ethnic identity, place, gender,
mothering, and the marketization of care. But
landscapes of care can also include those social
spaces where caring interactions or an orienta-
tion towards caring occurs but perhaps in less
palpable ways, such as schools, drop-in or home-
less shelters or the workplace (Conradson,
2003b; Crooks and Chouinard, 2006; Bucking-
ham et al., 2006); or in more fleeting ways, such
as the use of public space to demonstrate in sup-
port of the rights of (sometimes distant) others,
etc. In general, this body of work highlights the
geographic unevenness of landscapes of care
and how these both shape and are shaped by
other aspects of socio-economic change and
injustice at the urban and national level.
Landscapes of care are both product and pro-
ductive of social and political-institutional
arrangements for care. They incorporate contex-
tualized politics and policies as well as resources
for the provision of care – from the intimate and
local through to the macro-global and interna-
tional scales. They include embodied and situ-
ated personal and identity politics such as who
provides and receives care, where, when and
what it means for them, and situated institutional
arrangements such as patterns of service provi-
sion, but they are also bound up with equally
situated institutions such as culture, home and
family. Understanding how these landscapes
materialize and are understood in particular
ways also requires an appreciation of temporal
shifts and elements of care that are connected
to sociostructural processes as well as to the indi-
vidual – that is, how the experience and meaning
of care is related to: past experiences and future
expectations; the various temporal rhythms and
routines of care that can extend to stages in care
740
Progress in Human Geography 34(6)
relationships or care-giver ‘careers’; cycles of
welfare and economic support; health system
arrangements in a particular locality; and devel-
opments in monitoring care technologies. These
landscapes will, of course, be experienced in dif-
ferent ways by different groups of people
involved in the care relationship.
Hence, landscapes of care are multilayered in
that they are shaped by issues of responsibility,
ethics and morals, and by the social, emotional,
symbolic, physical and material aspects of car-
ing referred to above. This includes support, ser-
vices and the spatial politics of care. While each
of these aspects forms part of what constitutes a
landscape of care, it is also more than the sum of
these parts. It incorporates the human and spatial
relationships of care, the norms, values and rela-
tionships often inherent within care networks
(such as assumptions about formal/informal and
lay/professional care, individual versus collec-
tive care, the public/private dimensions of care,
care of self and others, paid/unpaid care-work,
or the rights and responsibilities of families com-
pared to collective society). Understanding such
tensions can also be connected to work on moral
and compassionate aspects of care – for exam-
ple, whether care and care-giving is based on
altruism, guilt or reciprocity (either immediate
or long-term). It can also be used to understand
gaps and absences of care, or even negative care
as in cases of abuse either of care-recipients or
care-givers. In sum, landscapes of care refer to
the complex embodied and organizational spati-
alities that emerge from and through the rela-
tionships of care.
III Troubling space: Proximity and
distance, caring about/for
In their efforts to tackle the complex and spatial
nature of care, geographers have engaged with
broader debates on the distinction between car-
ing for and caring about (eg, Tronto, 1989:
282–83; Graham, 1991; Grant et al., 2004). The
former implies a specific subject as the focus of
Milligan and Wiles
caring, while the latter is characterized by a
more general form of commitment that refers
to less concrete objects. Caring for is thus seen
to encompass the performance of care-giving,
including the activities undertaken by formal
paid workers or informal, unpaid workers such
as family, friends and volunteers. It exceeds the
norms of reciprocity commonly practised
between adults (Twigg and Atkin, 1994). At its
most fundamental, caring for is about the
personal, the performance of proximate and per-
sonal care tasks, but it can also include other
everyday tasks such as childminding, pet care
or household tasks. At a distance it can involve
arranging and monitoring paid and professional
care. Caring about on the other hand refers to the
emotional aspects of care; this might also
include the generalized relational and affective
elements of being caring.
As geographers we believe that this is a help-
ful distinction despite the fact that these terms
can be difficult to disentangle in practice. There
are many interactions between caring for and
about, which are present in varying combina-
tions in most care interactions or settings. This
distinction includes what we view as ‘care-ful’
or compassionate geographies (see section IV)
as well as more particular affective emotional
care about some body including the self, non-
human bodies such as animals, and the environ-
ment (Wolch, 2002; Conradson, 2005). It also
raises critical questions about how proximity
and distance is understood and whether, on the
one hand, we can care for as well as about distant
others in an embodied way, and, on the other,
whether the performance of proximate caring for
necessarily involves caring about.
Rather than challenging the distinction
between caring for and caring about, we suggest
there is a need to trouble the ways in which we
think about their relationship to proximity and
distance. We should not think of these relation-
ships solely in spatial terms, but recognize that
they also include social and emotional closeness
and distance. Much existing work on distance
741
and care takes a straightforward geographical
approach. Work by Joseph and Hallman
(1998), for example, demonstrated a strong neg-
ative relationship between distance and face-to-
face contact in care-giving, complicated by the
journey to work and gender patterns. G. Smith’s
(1998) review of work on the nature of interge-
nerational interaction between adult children
and their ageing parents shows that spatial
separation governs both the extent and form of
interaction. Smith maintains that while spatial
separation impacts negatively on these interac-
tions, families adapt, though the extent of ability
to adapt is mitigated by socio-economic circum-
stances. Work on bodily care and the home has
also tended to address proximity from a rela-
tively straightforward spatial perspective (eg,
Milligan, 2001; Williams, 2001). Even well-
used models for identifying types of support net-
works and the risk of isolation tend to draw on
geographical measurement as a proxy for dis-
tance and proximity (eg, Wenger, 1997). As a
consequence, such work on care has tended to
overlook or underestimate the frequency, impor-
tance and quality of alternative forms of contact
and proximity (for example, via telephone,
email, webcam or video-link) and the ways in
which advances in information and care technol-
ogy are contributing to the folding or collapsing
of the time-space continuum (Couclelis, 2009).
Though proximity is often used to imply
physical closeness, it can equally refer to social
or emotional closeness; physical distance does
not necessarily equate to disembodied care.
A care-giver might be physically distant but still
be closely involved in organizing care for the
care-recipient – for example, through contacting
agencies, monitoring care-work, providing
remittances, communicating with the care-
recipient with regard to their care needs, and vis-
iting where time and resources allow. Further, a
care-giver may be living in another city, country
or continent yet still be emotionally proximate.
These experiences of caring for and about some-
one can have a very immediate corporeality, not
741
742
only in the temporal rhythms and details of
dealing with time zones to make telephone calls
to care services and care-recipients or coping
with jetlag, but also the immediacy of contact
with service providers and other members of a
support network. Even where family members
are living in institutional settings, families are
often closely involved in care-giving, sometimes
in partnership with paid professional care-givers
(Milligan, 2006). Thus we suggest that caring for
is not necessarily reliant on physical closeness.
Likewise physical proximity does not necessa-
rily imply caring about (or caring for). Strained,
difficult or abusive relationships (or in the case
of paid care providers, social difference, poor
working conditions, or high staff turnover) can
mean a care-giver may not necessarily care
about the care-recipient and caring for might at
best be limited to ‘tending’.
Caring about should thus be understood as an
embodied phenomenon rather than a disembo-
died experience, even where care is physically
distant. It can occur across space and time zones
and manifest through a variety of forms of
contact. As it becomes internalized, caring about
can impact on and shape an individual’s per-
sonal politics and belief systems. One example
of the active performance of both caring for and
about distant others might be through an individ-
ual’s participation in a human rights organiza-
tion (eg, through carrying out letter writing
campaigns, collecting donations, organizing
protests). Raghuram et al.’s (2009: 6) work on
postcolonialism and care explicitly addresses
how the concept of caring about becomes
embodied through what they call ‘embodied
enactments of care’. Here, values from an indi-
vidual’s personal emotional relationships
become applied to more spatially distant social
relationships (and vice versa) as a way of think-
ing ethically and acting responsibly in an
increasingly interconnected world.
The spatial dynamics of proximity and
distance in the caring relationship are further
complicated by the rise of global care chains
742
Progress in Human Geography 34(6)
(Yeates, 2004) where migrant care-workers care
for (or tend) ‘unknown others’ in their host coun-
try and may be simultaneously caring both for
and about a physically distant relative in their
country of origin. At the same time, the increas-
ing use and development of care technologies
that enable remote monitoring and surveillance
means that caring for has the potential to become
progressively more disembodied (Milligan,
2009).
IV ‘Care-ful geographies’:
Citizenship and compassion
We suggest that geographical work informed by
interdisciplinary literatures on an ethics of care
might be usefully conceptualized as ‘care-ful
geographies’. In doing so, we posit that there are
subtle but important distinctions between this
literature and related geographical literatures
on the sociospatial and contextual aspects of
giving and receiving care, though both have
drawn from (and contribute to) wider social
science debates. ‘Landscapes of care’ is useful
because it provides an analytical framework
for connecting these literatures, both recogniz-
ing that care as a concept is not limited to
particular spatial locations, contexts or scales,
and refusing to leave it separated into overly nar-
row realms of the ‘political’, ‘social’, ‘economic’
or ‘health’, or care as ‘welfare’, ‘institutional’ or
‘embodied’.
The social and political construction of care
as a gendered concept has received much atten-
tion across the social sciences (eg, Finch, 1987;
Graham, 1991; Thomas, 1993; Tronto, 1993;
Twigg, 1989). Care, as both physical and emo-
tional labour, falls disproportionately on women
(Armstrong and Armstrong, 2002). Women also
undertake the bulk of paid care-work, which
is frequently undervalued and underpaid.
Researchers point out that this is reinforced by
political institutional landscapes built around
employment legislation and social support
which underpin normative assumptions of
Milligan and Wiles
women as the primary carers (Finch, 1987;
Ungerson, 1990; Graham, 1991; Lewis, 2002).
This highlights the social and spatial inequalities
around care and care-work that act as both
ideological and practical barriers to political
equality and participation for women (Staeheli
and Cope, 1994). But there is also a problem:
feminist researchers who focus on the everyday
(such as care-work) not only see profound social
differences in ‘the masculine and feminine’, and
between public and private spaces, but also
celebrate the emotions of mothering and ‘the
nurturing compassion they find in . . . domestic
[spaces]’ (G. Rose, 1993: 28; see also Dyck,
1989; Graham, 1991). The question thus
becomes one of how to understand and represent
women as social and caring subjects ‘without
referring to the figure of Woman’ (G. Rose,
1993: 137). In other words, how do we under-
stand the gendered experiences of care without
resorting to the argument that women provide
more care because they are inherently more
nurturing and caring?
Many theorists, including geographers, have
engaged with an ethics of care in trying to under-
stand and address these gendered aspects of care.
This feminist framework advocates equitable
values informed by specific context and valuing
care. An ethics of justice is a more rationalized
approach based on universal rules or laws.
Hence an ethics of care is concerned more with
responsibility and relationships than rights and
rules; and morality and frameworks for social
interaction are expressed as activity (of care)
tied to concrete circumstances, rather than
abstract principles (Tronto, 1987; 1993). Tronto
suggests that, instead of getting distracted by
debating an ethics of care (and care itself) as
either simplistically gendered or a feminine
form of development (eg, Gilligan, 1992), we
should focus on the adequacy of an ethics of care
as a social theory. Such challenges to crude
associations of care values with women and
justice orientations with men mesh well with
geographical perspectives (see also Svenhuijsen,
743
1998; Held, 2006). That is, an ethics of care
could be a framework not just for understanding
who gives care, where and why (ie, the interper-
sonal and institutional experience of care-giv-
ing) but also for understanding how an
approach informed by care might enlighten our
entire way of collective and individual being.
This characterizes what we call care-ful or
compassionate geographies.
Staeheli and Brown (2003), for example, have
engaged with the ways in which a feminist ethics
of care challenges conventional distinctions
between public space as the realm of politics and
justice and private space as associated with emo-
tion, care and welfare. They adopt an inclusive
approach to care and justice, refusing to partition
the two or ‘to place the emotion, the mess, and
the softness of care in some prepolitical zone
inaccessible to the purview of truly political geo-
graphers’ (p. 774). Instead, they emphasize the
acts and structures of caring that stretch across
public and private spheres and seek ways to con-
nect the individuals, communities and institu-
tions that shape care. Tronto (1993; 2002)
argues that the distribution of care and care
activities is an expression of power relationships
within a particular landscape. McDowell (2004)
argued that the ‘neoliberal condition’ combined
with current economic transformations is creat-
ing a growing unease about the balance of
responsibilities with regard to the physical per-
formance of care within the home and labour
market, in ways that disproportionately disad-
vantage women and men in low-skilled employ-
ment. Haylett (2003) further points out that
liberal feminist and neoliberal policy discourses
on women, work and welfare are effecting an
erasure of meaning, feeling and emotion from
the concept of care. Rather than tolerating
work-centric liberal and rationalist views that
regard welfare simply as unemployment com-
pensation or support en route back to work, she
argued that we need to look at welfare as a realm
of affective well-being and care. Thus the
political-economic shifts unfolding within this
743
744
particular landscape of care are argued not only
to be impacting on who cares and where that care
takes place, but by constructing care as work
these shifts increasingly distance caring for from
caring about. What the work of McDowell,
Haylett and others draws attention to is the fact
that what constitutes the giving of care, the
extent to which it is available, and who delivers
it to whom (and how), is defined not just by
sociocultural norms but also by the specific
nature and values of state regimes. Such shifts
can create differing gendered landscapes of care,
nurtured through social policies reinforcing
women’s position in supporting ‘stable’ family
life (Staeheli and Cope, 1994).
Geographers’ various engagements with
ideas around care-ful citizenship resonate with
other calls for a contextualized ethics of care
to inform not just the basic morals of interperso-
nal relationships but also conceptions of
democratic citizenship and political and global
affairs (Knijn and Kremer, 1997; Svenhuijsen,
1998; Held, 2006). Lawson’s (2007: 3) presiden-
tial address to the Association of American Geo-
graphers, for example, suggested a focus on the
‘specific sites and social relationships that pro-
duce the need for care’ and argued that caring for
and about socially and spatially distant others
can be seen as a form of citizenship. Masuda and
Crooks’s (2007: 257) call for an expansion of
ideas of citizenship incorporates multiple scales
and politics beyond the ‘public’ arena and the
national or urban scale, and includes intimate
as well as the ‘unfathomably complex, yet
lived-in’ scale of global relationships.
Popke (2006) also investigates placing an
ethics of care at the centre of geographical think-
ing. He suggests that rather than merging care
with an ethics of justice we might seek to under-
stand ‘care as a fundamental feature of our
being-human’ (p. 507) beyond the obvious sites
and spaces of care (such as institutions or hos-
pices). Popke draws on the moral philosophy
of Emmanuel Levinas, for whom the primary
aspect of Being or subjectivity is an ethical
744
Progress in Human Geography 34(6)
responsibility to the (unknowable) Other. Care,
Popke suggests, could inform more ethical
everyday practices and ways of being, such
as seeing our role as consumers as a
care-informed relationship. This might redress
the limitations of attempts to rectify injustices
in commodity chains through consumer demand
for ‘justice’ and ‘fairness’ (which in existing
systems of institutionalized practices and chains
from producer to consumer often becomes
fetishized and commodified itself).
To embrace an ethic of care as a potential
challenge to disempowering social and spatial
relations, we must seriously engage with its
problems (Tronto, 1989). For example, we do
not, and perhaps cannot, care for everyone
equally, hence an ethics of care could become
a defence for caring only for one’s family,
friends, group or nation. This raises hard ques-
tions about the appropriate boundaries of our
caring, and how far these could or should be
extended (Tronto, 1987: 659–60). Some geogra-
phers have pondered moral geographies of care
and beneficence, for example, in the context of
natural disasters, either by seeking to understand
how people act in relation to distant others
(Barnett and Land, 2007; Clark, 2007), or by
exploring acts of giving and the asymmetry of
the power relations involved in the relationship
between wealthy western donors and those who
are often viewed as ‘passive recipients’ (Korf,
2006a; 2006b).
Others have considered geographical debates
around the social and spatial extent of responsi-
bility and social justice (Harvey, 1996; D. Smith,
1998; Massey, 2004; Silk, 2004; Smith, 2005).
Within this frame of reference, the spatiality of
care is interpreted as an ethical concern emer-
ging from the ‘moral crisis’ that threatens con-
temporary western society (Smith, 2000a).
Society, Smith (2000b: vii) argued, has ‘lost its
moral bearings’ as it fails to get to grips with
increasing polarization between rich and poor,
growing intolerance to difference, and the pur-
suit of personal improvement over that of wider
Milligan and Wiles
society. Welfare retrenchment, coupled with the
market logics of competition and efficiency, is
viewed as underpinning the imperative for cut-
backs in care and social services, which impact
disproportionately on the poorest. Globally,
shifts toward the privatization of public and
social goods place control of some of the most
basic human needs (water, land, utilities,
plants/seeds, affordable housing) increasingly
into private hands (Lawson, 2007). These shifts
are manifest in a geography of poverty and
inequality that also reflects who has access to
care and who undertakes that care-work.
V Landscapes of care: A view from
health geography
It should be clear from the above discussion that
the interrelationship between care and place runs
across a wide range of work within human geo-
graphy. This has been particularly true within
health geography, where commentators have
been concerned for some time with the spatial-
ities that emerge through relationships of care
(Parr, 2003), and the embodied, contextual
nature of care-giving. In this final section we
thus turn to work from within this particular sub-
discipline and consider how health geographers
have been contributing to the notion of a land-
scape of care and engaging with proximity and
distance in relation to both caring for and caring
about.
1 The changing topography of care
In this section we explore the relationships
between broader political-economic influences
and the places in which care takes place. Spe-
cific changes in the ‘topography’ of landscapes
of care over time have had fundamental implica-
tions for the meaning and experience of care.
One body of work around care in health geo-
graphy has been concerned with the ‘community
turn’ (Macmillan and Townsend, 2006). This
‘turn’ emerged from the neoliberal and post-
745
neoliberal shifts which occurred in many
advanced capitalist countries from the latter half
of the twentieth century, contributing to a chang-
ing topography of care. This work has taken as
its focus the redistribution of responsibility for
care between statutory, voluntary and private
bodies, as well as family, friends and neighbours
(eg, Wiles and Rosenberg, 2003; Milligan and
Conradson, 2006). Variations in the balance of
this responsibility for care are shaped by a range
of factors including shifting welfare regimes,
differing ideologies of care, social and cultural
traditions and changes in the level of care
required by particular individuals. Who cares,
where, thus varies over time and place.
While the neoliberal drive toward welfare
pluralism in many advanced capitalist countries
has resulted in an increased role for third- and
private-sector care providers alongside that of
the state (Milligan, 2001; Owen and Kearns,
2006; Skinner and Rosenberg, 2006), few would
argue that professional care provision could ever
completely replace that provided by informal
care-givers. Most community health and social
care services would be unable to cope without
their contribution (Wiles, 2003b). Whether sup-
port for informal care-givers is high on a coun-
try’s public policy agenda is linked to debates
around rights versus responsibilities to care, as
well as who pays and controls the resources to
purchase and provide services (Glendinning,
2000).
Caring for may be thus be undertaken by pub-
lic or private bodies in both public and private
spheres and may include the management and
negotiation of routines, schedules and relation-
ships as well as everyday care-work. The priva-
tization of care reflects the relative social power
of different groups in society to make their con-
tribution more highly prized and recognized.
Those who are more powerful in society have
a greater ability to see that their caring needs are
met under conditions most beneficial to them,
even if this is at the expense of the care needs
of those providing the service. As noted in
745
746
section IV, such shifts can create differing
gendered landscapes of care. This also reflects
deeply rooted beliefs that men are less able to
take care of themselves or others (Arber and Gil-
bert, 1989). Bywaters and Harris’s (1998) work
in the UK highlighted the potential for gender
bias in professional responses to male and
female care-givers. Women care-givers were
less likely to be offered the support of public ser-
vices than men despite the fact that women are
more likely to take on a heavier caring role.
Though this study is highly localized and
small-scale, such bias is likely to occur in many
care support systems, thus reinforcing gender
inequalities in access to formal services (Wiles,
2003b).
Understanding ‘who cares’ thus requires an
appreciation of differing political and sociocul-
tural constructions and interpretations of care.
For example, in many societies, particularly in
non-western countries, traditional family-based
systems of care-giving are still the norm, and
care is defined as a private activity built around
values of familial obligation. In contrast, social
democratic countries such as those in Scandina-
via have a history of collective state responsibil-
ity for the long-term care of frail and vulnerable
groups; hence public provision of care services
is well developed. Conversely, though the post-
socialist regimes of eastern Europe have a histor-
ical legacy of collective responsibility and
provision, the collapse of socialism during the
late twentieth century meant that state care also
largely collapsed. With private and home-based
care services underdeveloped in comparison to
that of western democracies, the responsibility
of care has been shifted largely back onto private
citizens (Milligan, 2009).
In many western countries the concept of
‘care-in-place’ through the advancement of
deinstitutionalized (or community) care services
has developed since the mid-1970s. Of course,
the concept of community care never really
meant care by local communities; rather, it
referred to the development of new spaces
746
Progress in Human Geography 34(6)
of care-giving located outside traditional
institutional environments. These traditional
arrangements have been replaced by what
Domènech and Tirado (1997) refer as ‘extitu-
tional arrangements’: emerging entities that may
resemble the old institutions, but which are vir-
tual and apart from the building. The extitution
thus represents a deterritorialization of the insti-
tution and its remanifestation through new
spaces and times which potentially end the inte-
rior/exterior distinction of the institution
(Vitores, 2002: 2). The old institutional forms
of attendance within a physical (institutional)
structure are replaced by horizontal processes
that are dispersed across space and which can
include physical, affective and virtual networks
of care (for example, through webcam and tele-
care technologies).
The extent to which such extitutional care
arrangements are an improvement over the old
institutional ones is debatable. Caring for frail
older people at home can mean increasing
isolation and individual institutionalization
within the home (Milligan, 2003; Wiles,
2003a; 2003b). Others point to a new world of
mental healthcare where recipients live in highly
institutionalized spaces differing from the for-
mer institutions only in their high levels of frag-
mentation and toxic isolation. Despite the many
failings of the old institutional regimes, care-in-
place also disrupts the interactive layers of
‘community’ (eg, between patients, clinicians
and support staff) that existed in those institu-
tions and which, for some, created an oasis of
calm and safety during periods of acute distress
(Lentis, 2008).
Changing topographies of care are also
related to developments in technology, such as
remote monitoring technologies that create new
spaces of care (eg, call-centres and internet
access sites), enabling care at a distance. These
technologies involve new groups of workers
(eg, technicians and call-centre operators) in the
care economy and create new roles for the
existing workforce (Mort et al., 2008). But
Milligan and Wiles
surveillance care technologies in the home also
hold the potential to substantially alter family
relationships where conflict arises over access
to personal data (Tracy et al., 2004; Morris,
2005). Hence new care technologies contribute
to a new topology of care, reshaping care and
care relationships both within and across the tra-
ditional boundaries of home (Milligan et al.,
2010).
2 (Re)Locating care: the shifting boundaries
between public and private
Broader shifts in the topography of care impact
the experience of care at the micro-level. Health
geographers, for example, have pointed to
increased blurring of boundaries between spaces
formerly considered public or private, and
between institutional and non-institutional
spaces. These can range from the domestic home
to alternative spaces of care such as halfway
houses, supported accommodation, retirement
villages and care homes. Deinstitutionalization,
extitutionalization, shifts to community-based
care, policies focused around ageing in place,
and the growth of remote care technologies all
have implications for who cares, where, and the
nature of the care-work they undertake. Work
within health geography, more specifically,
illustrates that where care takes place and the
care-giving experience are interrelated.
The focus on increased formal and informal
care within the domestic home has manifested
in many shifts in the social and symbolic
meaning and physical nature of the home itself
(Milligan, 2000; Wiles, 2003a; 2003b; Dyck
et al., 2005). Twigg (2000) maintained that care
in the private space of the home acted to
empower the care-recipient by placing the
power to exclude firmly in his or her hands
(based on the norms of visiting and privacy
within the home). As others have pointed out,
however, this will shift as the extent of care
support required increases (Milligan, 2003). Fur-
ther, though care provided in the home may be
747
viewed as preferable by many care-recipients,
it can also be disruptive, creating changes in the
relationships normally exhibited within the pri-
vate space of the home (Milligan, 2001: 173;
Wiles, 2005). For both care-recipients and fam-
ily carers, changes in their sense of home and
how they identify with the home can cause much
difficulty in itself (Wiles, 2003a) and at its most
extreme has been referred to as an institutionali-
zation of the home (Milligan, 2001).
As care provided at home is less publicly
‘visible’, the shift from care in institutional set-
tings to more fragmented, private, often less-
visible community-based settings both enables
and is shaped by a stealthy informalization and
privatization of care as the costs of care are
shifted away from collective society to individu-
als and families (Wiles and Rosenberg, 2003).
Work formerly undertaken by registered nurses,
for example, has increasingly become the remit
of care support workers and auxiliary nursing
staff and family members are increasingly
expected to perform technical tasks formerly the
remit of nursing and care staff (Milligan, 2000;
2001; Ward-Griffin and Marshall, 2003; Wiles
and Rosenberg, 2003).
Providing care in the domestic home also has
implications for the protection and working con-
ditions of paid health and service professionals.
Paid ‘community care’ workers are often already
minoritized (eg, immigrants, cultural groups)
and work with little training or support, and are
potentially vulnerable to abuse from clients.
They are frequently paid less than those with
equivalent qualifications working in hospitals
or clinics, and have less job security. As they
do not work in a common ‘space’, they have
fewer opportunities to interact with each other,
meaning it can be difficult for care-workers to
collectively organize (Meintel et al., 2006).
Other problems range from contestation over
home aesthetics and the need for a sterile work-
space through to working conditions such as air
quality and transportation problems (McKeever,
1999; England, 2000). Nevertheless, as Meintel
747
748
et al. (2006) pointed out, their mobility and the
distance from the institutions which employ
them can also allow community workers consid-
erable autonomy and even freedom to provide
services in creative ways beyond the formal
requirements.
Hence as Brown (2003) noted, the home as a
site of care presents a spatial paradox. Drawing
on political geographies and critical theory, his
work on home hospice care illustrated the ten-
sions between understandings of home as both
a good and a bad place to receive care – as a site
of patient control but also of lack of control, of
both autonomy and dependency. Similar ten-
sions are evident in the transition from home to
residential care facilities, as managerial staff’s
concerns around risk avoidance and legal obliga-
tions are balanced against care-recipients’ need
to feel some autonomy and independence; and
informal care-givers find themselves having to
renegotiate their caring identities in the new
place of care (Milligan, 2005; 2009).
Other health geographers, such as Gleeson
and Kearns (2001), have sought to examine the
moral place-related binaries associated with the
process of deinstitutionalization, arguing for an
inclusive ethics of care that would open up more
flexible spaces and understandings of the places
and spaces in which care can occur. Conradson
(2003b: 521), observing how articulating a car-
ing stance can create calm, positive spaces in
an urban drop-in centre, suggested that we
should pay more attention to the unexpected
spaces of care because of the ‘hopeful and at
times transformative relations that emerge
within these settings’. Others have begun to
explore the tensions and opportunities that can
occur as institutions themselves are changing
from clinically dominated settings to those
organized around social models of care. Curtis
et al.’s (2007) study with providers and well
patients using a mental health inpatient unit in
London, for example, emphasized the tensions
between the perceived need for security and
surveillance versus freedom and openness, and
748
Progress in Human Geography 34(6)
the need to empower patients through their
involvement in decisions over hospital design.
All these works point to an imperative to recog-
nize and unpack the multiple meanings of places
(particularly, but not exclusively, the home) as
sites within which to explore rapidly changing
geographies of care (Williams, 2002).
VI Concluding comments
We set out in this paper to unpack and elucidate
what a landscape of care might look like. While
our final section focuses on health geography,
we have drawn on work addressing care across
a broad spectrum of human geography. Social
and cultural geographers have engaged with care
very much at the level of the body, embodiment
and emotions; but they have also extended the
notion of care to non-human relationships such
as animals or the environment. Social feminist
geographers have for a long time written about
the connections between childcare, work and the
state and how these negotiations shape gendered
power relations and experiences, often working
at the urban and regional scale. Political, eco-
nomic, environmental and development geogra-
phers are increasingly engaging with the ethic of
care in thinking about the redistribution of
resources and reorganizing of institutional
arrangements, often at the global scale as well
as national and institutional scales. This high-
lights the vibrancy of work around care but, as
we suggested at the outset, if these literatures are
to ‘talk to each other’ it is important to draw out
the commonalties. Of course the boundaries
between subdisciplines are nowhere near as
clear-cut as this paper might imply – indeed we
recognize the messiness between these bound-
aries. Our concern here has been to find a way
forward, one that draws out the potential points
of contact and overlap in a way that might enable
these overlapping subdisciplinary approaches/
discourses to talk to and connect with each other.
Our project does not seek to elevate the
importance of local or individual understandings
Milligan and Wiles
over global concerns for care or vice versa,
indeed in our paper we have attempted to clarify
some of those issues that we feel stretch across
all of the above. In particular, we point to some
of the tensions of care that are evident within a
number of these discourses: care as a form of
dependence or independence; care as public or
private activity; care as paid and unpaid work;
care as a right or responsibility; care as an emo-
tional or physical response. As geographers, we
also add the tension between public and private
spaces of care and their social embodiment.
Landscapes of care incorporate mutually consti-
tutive public and private spaces, flows between
them, and moral and ideological frameworks
that have implications for care.
We have also sought to engage critically with
some of the geographical debates around care
through the various interconnected scales at and
through which care takes place, reworking both
into a literature on landscapes of care. In partic-
ular, in thinking through the complex embodied
and organizational spatialities intrinsic to land-
scapes of care, we have sought to trouble ideas
of proximity and distance and the messiness of
trying to understand their relationship to caring
for and about. In seeking to disrupt traditional
geographical ideas about proximity, we suggest
that even physically distant care-givers can be
affectively or socially proximate, and that physi-
cally distant care relationships can be literally
embodied. We have also examined the connec-
tion between what we call care-ful geographies,
and more specific work on geographies of care-
giving. We believe that these broad traditions
have much to say to each other, and that by enga-
ging in such discussion geographers can make
important contributions to interdisciplinary
understanding and practice.
In sum, landscapes of care encapsulate the
spatial manifestation of care within and across
interconnected scales and the ways in which care
is woven through the fabric of particular social
spaces. As the complex embodied and organiza-
tional spatialities within and across which care
749
and care relationships take place, and as an
emphasis on the contextual and located nature
of care, we see landscapes of care as a helpful
analytical framework.
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