Approaching Health in Landscapes

An Ethnographic Study with Chronic Cancer Patients from a Coastal Village in Northern Norway

in Anthropology in Action

Abstract

Chronic cancer patients (CCPs) pay attention and act in response to diverse bodily sensations they experience in everyday life after a cancer episode. Here, we analyse how North Norwegian CCPs use their familiar surroundings in an effort to counter bad mood, anxiety and symptoms of relapse and to strengthen their health. The core participants of the anthropological fieldwork over the course of one year were 10 CCPs from a small coastal village in northern Norway. By drawing on Tim Ingold’s understanding of taskscape, it is suggested that the participants after cancer treatment dwell in and engage with the surroundings of the village, including the core task of staying healthy. The participants are part of and embody the landscape through the temporality of taskscape, related to their ways of dealing with pain, worries and bodily sensations in everyday life.

Studies have shown that chronic cancer patients (CCPs)1 are concerned about possible relapse and their health in general (Harrington et al. 2010; Larsson et al. 2008). Previous research has shown how people perceive certain places to be therapeutic and positive for their health when dealing with illness (Gesler 1992; Williams 2007). Other studies have shown how CCPs experience significant healing dimensions of engaging with landscapes that are familiar to them and how it influences their perception and experience of bodily symptoms and well-being (Harley et al. 2012; Harrington et al. 2010). O’Brien and Varley (2012) suggested the use of ethnographic methods to gain important insights into why people engage with natural surroundings to gain health benefits. No ethnographic studies have yet contributed insight into how CCPs dwell in landscapes that are familiar to them to avoid relapse and stay healthy, and shown the fluidity and temporality of approaching health in local and meaningful ways.

Anthropologists and geographers (Bender 2002; Ingold 1993, 2000, 2007; Olwig and Jones 2008) have demonstrated that landscapes are more than the mere physical appearance of natural surroundings but are subjective and the creation of people’s understanding and engagement with the world. One point Ingold (1993: 154, 166) emphasises is distinguishing landscape from land. While land is quantitatively measurable and homogeneous, landscape is ‘felt’ and perceived, especially through movement. Humans shape these landscapes while they dwell in them, and their activities contribute to the process of erosion (Ingold 1993: 167). From Ingold’s perspective, landscapes are not surroundings that everyone can see, but he motivates us to imagine them as the world in which a person stands and from there develops a point of view on them. ‘Landscapes’ are not ‘nature’, as they become part of us while we dwell in them and are therefore implicate and not explicate, as the concept of ‘nature’ is (Ingold 1993: 152).

Ingold (1993: 158) refers to the entire ensemble of tasks carried out by skilled agents in a surrounding, which is a part of his or her normal business life, as the concept of taskscape. Taskscape exists as long as people are engaged in activities of dwelling in specific surroundings (Ingold 1993: 161–162). For Ingold (1993: 172), ‘the process of dwelling is fundamentally temporal, and the apprehension of the landscape in the dwelling perspective must begin from a recognition of its temporality’. Temporality can be imagined as a part of the experience of those who, while conducting their activities, carry forward the process of social life (Ingold 1993: 157). Thus, the use of Ingold’s concept is an attempt to bring forward experience-near accounts and the intentions of people while being-in-the-world rather than attributing cultural ideas and beliefs to their specific actions (Ingold 1993: 162). Inspired by Heidegger’s ([1951] (1997)) speech/text ‘Building, Dwelling, Thinking’, Ingold is interested in moving beyond seeing landscapes from a culturalistic perspective as a cognitive or symbolic ordering of space (Ingold 1993: 152).

In this article, the term ‘surroundings’ is used to refer to the mere physical dimension of the natural area around the village, which will later be described in more detail. The term ‘landscapes’ refers to Ingold’s concept of a practiced, lived space, dwelt in and embodied. The perspective on landscapes contributes to the understanding of how participants engage in their surroundings, which are physically close to them, with their own specific perspectives. Ingold’s concept of ‘taskscape’ specifically contributes to understanding how tasks in surroundings that are meaningful for the participants are activities that live and embody the landscape as tasks of staying healthy. The entire ensemble of tasks includes gathering, enjoying, knowing and staying healthy in general, but are epitomised for CCPs to concern the tasks of pain relief, avoiding relapse and dealing with anxious feelings. Certainly, participants also perform other physical activities or develop habits that promote health, which is not quite relevant for this article because it does not try to make claims about the concrete medical effects of those experiences on health. Rather, this article is about how participants think about health and approach it in culturally relevant ways and contexts – being outdoors in familiar landscapes where health and purity are inherent dimensions.

Additionally, we use Leder’s perspective on ‘The Absent Body’ (1990), which shows how a healthy person’s awareness of his or her body often changes when he or she becomes ill. Leder’s underlining of the change from absent to present contributes to understanding how familiar activities in landscapes can become new tasks, that is how many well-known activities and landscapes become attached to the awareness of the body and the task of staying healthy.

This becomes less abstract considering that we are located in Norway, where moving the body outdoors is historically rooted. In the process of liberating from Denmark in the nineteenth century, the unique Norwegian surroundings were associated with free farmers in a democratic nation, and the mountains and agricultural areas with freedom, peace, naturalness and healthiness. The more the industrialisation process progressed, the more the unexploited nature was valued, thus stimulating the creation of a nostalgic longing for a simple and natural life (Frykman and Löfgren 1987). The idea of ‘the good life’ in the mountains and other natural surroundings was also reinforced by environmental debates in the 1960s and 1970s. The mountains were highlighted as a recreation area where people can come into contact with sides of themselves that are perceived as more authentic, natural and pure than they are in cities (Baklien et al. 2015; Gunnar 2003; Norbye 2009). Today in Norway, activities in nature are often considered to be more varied and to stimulate the senses better than other activities. These activities stimulate both competence and confidence, which are considered important for children to learn (Bjerke 1993). The composition of the concepts ‘nature’, ‘freedom’ and ‘purity’ is positively connected in Norway and associated with a healthy lifestyle (Witoszek 1998). It is believed among Norwegians, and our participants, that being in nature makes the body stronger (Gullestad 1992; Witoszek 1998). Drawing on Ingold’s concepts, the aim of this article is to analyse how the effort and wish of staying healthy is linked to dwelling in familiar landscapes and how health is approached in those landscapes by CCPs.

Into the Village

The fieldwork was conducted by the first author in a coastal village with less than 3,000 inhabitants (undisclosed due to anonymity) in Finnmark, the northernmost county of Norway. The village faces the open sea to the north, and inhabitants often experience strong winds and storms, especially in the wintertime, and a foggy climate in the summertime. In the other directions, the village faces open, partly hilly surroundings. The two-hour flight, which has a lot of delays and cancellations, to the nearest hospital with medical doctors specialised in cancer, and the isolated geographic location in general are challenges for patients.

In 2011 most people worked in the service industry, the secondary sector of the economy, or the municipal health and care services. Even though the fishing industry has grown smaller over the years, it is still considered to be the main industry in the village (Folkvord and Foss 2013). The village has a primary and secondary school through the tenth grade. Most adolescents decide to go to high school in larger villages in the same county. People who walk a lot, ride bikes or hike in the mountains experience great appreciation; for example, those who register their names often in a tour book get small gifts from the local Badminton Club. Most families in the village have cabins close to a nearby river, which is highly appreciated for salmon fishing. The fishing club has one of the largest memberships among the leisure organisations.

Ten CCPs (four men, six women) were recruited through the local general practitioner, the local cancer nurse, acquaintances and an announcement in the local newspaper. The participants, who were all Norwegians and inhabitants of the same village, had different types of cancer and were between 41 and 82 years of age. Nine of the patients had finished conventional cancer treatment. One participant still had cancer, which was kept at bay by three different radiotherapies. The timespan since treatment varied between three months and 10 years before the start of the study – all of the participants had resumed their everyday life. Participants had different experiences related to the diagnosis; from an uncomplicated operation four years ago, to experiencing relapse and living with complications.

An anthropological fieldwork design (Emerson et al. 2011; Hammersley and Atkinson 2007; Spradley 1980) was selected, and the first author lived in the main village for about a year in 2014. She regularly participated in leisure activities and spontaneous and locally occurring events with the participants and other inhabitants of the village – going for walks and taking part in the local choir, knitting club and orchestra, where she met both core participants and other inhabitants regularly.

Biographical interviews and monthly semi-structured interviews were conducted with the 10 core participants. The biographical interviews (Flick 2012; Kuesters 2009; Schuetze 1983) focused on the participants’ illness stories and formed a basis for the monthly semi-structured interviews (Kuckartz et al. 2008). The monthly interviews included questions about well-being, perceptions concerning bodily changes, bodily sensations and symptoms. The conversations and observations of the first author as she spent time with some of the participants in the natural surroundings near the village, are the main empirical basis for this article and why some descriptions are written from her perspective. Almost all participants pointed out that the task of approaching one’s health is embedded in spending time outside. The first author spent much time walking and hiking with Synnøve and Terje, who both expressed and experienced connections between being and moving in their landscapes and staying healthy. They are the protagonists of this analysis.

Ethical Considerations

The study was funded by the Research Council of Norway. Participants provided informed consent and had the option to withdraw from the project at any point. The participants were assured that any information they provided would be treated with confidentiality and de-identified. Thus, all participant names have been changed. The project addresses the sensual, emotional and relational aspects of the patients’ illness experiences. This means that patients and their significant others were vulnerable both during fieldwork and by being included in the analysis. Special care and sensitivity was needed to protect and respect the patients’ integrity throughout the study. The research group worked specifically on these issues during the study.

Interpretation

The encounters with Synnøve and Terje illustrate the associations the body and bodily movement receive in their familiar surroundings after cancer treatment. Like Terje, Synnøve did not start new activities that are supposed to be good for cancer patients and recommended by health professionals or the Norwegian Cancer Society2 (Skarpaas 2012), which has norms for how much they should walk or work out each day or week. Instead, they see occasions to extend their perception towards a healing and illness preventative dimension in familiar landscapes.

Terje’s experiences in the surrounding are based on years of dwelling in it; an embodied foundation for his understanding of his landscapes as partly involving healing qualities. The encounters with Terje show how the same surroundings can be experienced fundamentally differently by individuals, and how not everyone may necessarily experience healing dimensions in them. Synnøve shows us how one can combine a life marked by pain and some episodes of frustration with outdoor hobbies, most of which appear to have healing elements for her, especially since she had cancer.

Terje

Terje had colon cancer and has to live the rest of his life with a colostomy bag. I met him just a couple of weeks after surgery, when he was almost back to his usual physical strength and started to walk on a regular basis again. He is over 80 years old, lives by himself and spends almost every day all year round in the natural surroundings near the village, mostly walking. He grew up in the countryside and worked as a fisherman like his father. His mother mainly took care of the farm and his siblings. He always collected berries in the autumn to help feed the family. Now berry picking earns extra income for him; he sells berries to the local health centre or other places in the village. Fishing was also an activity that ensured the family’s nourishment. Now it is a hobby, and fish is still an important part of his daily diet. In the summer, he lives in his cabin, which is about an hour’s drive from the village. He pointed out several times how relieved he was when he could start his daily walks soon after surgery and change the colostomy bag himself, allowing him to spend the summer at his cabin without getting help from employees at the health centre. In the surroundings of his cabin, he usually fishes until his freezer is full or he smokes the fish. In addition, he makes things out of wood, fixes things around the cabin and does crosswords, among many other things that he enjoys.

Terje and I walked often together from the main village to the airport and back. The whole walk is about eight kilometres via a small path along the shore to the airport and the main road back. When I started living in the village, I perceived the vegetation as rough and stony, lacking trees and bushes. The grass retained its yellowish colour for a long time after the long winter. Terje’s detailed descriptions of the surroundings were different from mine. While we walked, he stopped from time to time to explain particular plants – why they grew there and what they could be used for. He constantly observed the ocean, and even though the boats were far away, he immediately knew which fishing method they were using. He used to explain how the surroundings changed after the airport was built, where there used to be cabins and at which places people used to sleep in tents during the German occupation during the Second World War. At the seashore, he would pick up one of the various items found there, such as old rubber boots, gloves, whalebones or seashells, and explain their function and why they ended up in the ocean.

His engagement with the surroundings within walking distance from his house was shaped over a long lifespan by his experiences and habits. Each time we reached the airport, Terje would list our names in one of the tour books and we would reward ourselves with cookies. On the way back, Terje sometimes introduced me to some friends that we met on the main road. Once home, we rewarded ourselves again: homemade fish cakes and hot coffee. When I asked why he walks so much, Terje said that it simply keeps him going. He believes that it contributed to many years of health and his quick recovery from cancer. Talking about the number of berries he was picking, he said: ‘Jeg gir meg ikke enda’ [I am not giving up yet]. Subliminally, he points towards his age, the circumstances of the former cancer illness, and that he is still able to stand the weather and effort. Instead of giving long complicated explanations about the benefits of walking and why he spends so much time on this daily routine, Terje simply showed me how he relates to and is involved with his landscape. He demonstrated a certain implicitness that spending his time outdoors the way he does is simply good for him, not only since he had cancer but especially since then. This implicitness was established while conducting temporal, constitutive acts of dwelling in his landscapes; years of embodying experiences and activities, which built up his knowledge about how his body is while being in those landscapes.

In contrast, engaging with this particular physical surrounding was a new thing for me – it remained exotic and walking or being in it was not a part of my daily routine. Terje’s perception of the surroundings was shaped by the difficult times during and after the Second World War and other historical events; his habits of using nature during his adolescence and childhood; his daily walks; the resources, in terms of food, that the surroundings have to offer; and his life as a fisherman. The ways the exact same physical surroundings were a part of him and me were fundamentally different; the many hours of being in those surroundings created Terje’s subjective temporality of the landscape.

Terje is determined to keep himself going physically. Even shortly after the cancer treatment, he continued his familiar activities. The rapid re-adoption of those old activities is important to him and even a part of his recovery. A possible and sudden lack of accessibility to his cabin and the surroundings would mean a decisive turning point in his habits and current recovery strategy.

Synnøve

Synnøve engages with the landscape specifically for recreation, healing and well-being. In the arctic and hilly area within walking distance or a half hour drive from the village, she goes skiing, walks the dogs, goes fishing, collects seagull eggs and spends time at her cabin. She is in her 50s, lives with her husband, and has two adult children. Synnøve had two different types of cancer (colorectal and Hodgkin-Lymphoma) at different points in her life and lives now with chronic, daily pain in her joints, especially her feet, which is a late effect of chemotherapy. Even though she worked full-time after treatment, she had to reduce her work to part-time because she was struggling with fatigue. In her spare time, she tries to be outdoors as much as possible.

Synnøve took me out for a hike in June, when the last of the snow was melting. Similar to my informant Laila, who was diagnosed with ovarian cancer a couple of years ago, Synnøve explained how walking on the soft and irregular ground helps relieve the pain in the joints of her feet and to forget the risk of a possible relapse. With detailed descriptions, she illustrated how the little, uphill trail we took felt soft and uneven. For her, it is the perfect ground: massaging for her feet and not too hard. On some days, it is the only ground she is able to walk on; conversely, walking downhill or on asphalt for long distances can cause her pain. Therefore, she feels that she has no choice: she has to be and stay active in the natural surroundings, where we walked along.

Although her general practitioner recommends painkillers on a regular basis, even when she is not experiencing acute pain, she often decides not to take them, and goes for a walk or hike instead. Synnøve does not like to take pills before she even knows how strong the pain is going to be, but prefers being outdoors, which helps relieve her worries, frustration and physical pain related to the diagnosis. In many ways, Synnøve hinted to something that Torleif, an informant who was diagnosed with non-Hodgkin lymphoma in 2003,3 spoke of in one of the interviews: being outdoors makes the body stronger and less vulnerable to upcoming illnesses.

While walking, Synnøve explained: ‘Jeg tar den stien når jeg er sur’ [I walk this path when I am upset]. Walking on this particular path became one way for her to deal with emotional or psychological difficulties, not just related to cancer but also non-cancer-related situations. Synnøve is an example of how one can be in these specific physical surroundings, or how she is in her landscape, practising tasks that enable her to approach health. For Synnøve, walking and spending time outside has a new connection, to cancer. She walks specifically to get rid of pain or anger connected to the diagnosis and to strengthen the body, and the light-hearted movement outdoors has an additional focus on pain relief and dealing with the risk of relapse. Synnøve’s activities changed from tasks like gathering, enjoying and knowing the surroundings, and staying healthy, to additional engagements that actively attempt to relieve pain and handle worries. A key part of this is that Synnøve knows how the ground actually feels or may feel under her feet, because she and other generations performed this activity before. Not least of all, she knows how walking tours influence her and others’ mental condition and did so also before she was ill. Previous activities performed by her and others in the mentioned surroundings shape the landscape and its temporality, and can be seen as a basis on which she can build to perform her ‘healthy tasks’.

By including Leder’s perspective on ‘The Absent Body’ (1990), we gain access to how the individual perceptions of Synnøve’s and Terje’s bodies have changed after cancer diagnosis and treatment, which creates an understanding of how familiar engagements in the surroundings receive healing associations for them. According to Leder (1990), individuals often pay little attention to their bodies in everyday life, but bodily awareness and perceptions change after or during illness. For example, most of the world surrounding us is made by hands, and even for hands (e.g. door handles, kitchens, or all kinds of tools). However, the hands are transparent because people hardly ever pay attention to their hands while they do things with them. Thus is the healthy body in everyday life – transparently caught up in the world of engagements and involvements. Only when there is a dysfunction or a moment of breakdown does the flesh enter our awareness (Leder 1990). Since Synnøve became ill and went through chemotherapy, she has been almost constantly aware of the pain in her feet and experienced dysfunction while involved in her outdoor activities. She now finds solutions for the pain by keeping herself active with the same activities she performed before she became ill, and in the same landscapes. This change from an ‘absent’, pain-free body makes it understandable how a familiar activity can become attached to one’s awareness of the body and the task of staying healthy.

Concluding Perspectives

Both Terje and Synnøve changed their focus of being involved in their landscapes to prevent illness. This means that they mostly keep their old routines of walking, skiing and fishing, but the meaning of those routines have changed. Synnøve and Terje have positive experiences with being outdoors, and embody and incorporate those experiences and engagements. The specific tasks they used to perform are relied upon and revived as an assembled part of their changed bodies – being in those landscapes and reconfiguring the relationship between body and landscape. All human experiences, including being ill, are rooted and remembered in the body (Leder 1990), which means that one interprets bodily changes based on these embodied experiences. Thus, the experience of being ill occurs in connection with previously embodied being-in-the-world. Which activity is the ‘right’ one is determined through the specific temporality and patterns of dwelling activities that are inhered in it. While moving in landscapes can take the attention away from Synnøve’s potentially ill body, it also focuses her attention on a bodily condition and under which circumstances she may experience a feeling of being healthier. In other words, ‘the body-in-the-landscape’ is a relational enactment that works both ways, healing the body and restoring the landscape at the same time.

The analysis of Terje and Synnøve shows how embodiment can be understood as a movement of incorporation and being-in-the-world rather than the realisation of a specific cultural template (Ingold 1993: 157). How participants embody familiar landscapes in accordance with their habits and experience during and after an illness state was illustrated with Ingold’s (2000) theoretical perspective on taskscape. Understanding taskscape as landscapes in which people are engaged with activities of dwelling allows us to understand why and how participants are able to approach health in those surroundings and try to improve daily life in general. The analysis brought forth experience-near accounts and the intentions of people while being-in-the-world rather than attributing cultural ideas and beliefs to their specific actions.

The encounters with the participants indicated how dealing with bodily sensations on a daily basis occurs apart from the official healthcare system in a private, familiar setting and under local circumstances. CCPs are confronted from different directions with demands for regular physical activity. This article demonstrates how participants conduct ‘healthy tasks’ that include physical activity and occur in non-rigid forms and schedules in which the participants take advantage of moving in and restoring relationships with familiar landscapes.

Note
1

The definition of the term ‘chronic’ in relation to cancer varies. Here it points out that cancer is, in most cases, not a temporary disease. It can mark someone’s life even after the therapy, via late effects and uncertain bodily sensations, which indicate the risk of relapse.

2

The Norwegian Cancer Society recommends 60 minutes of moderate or 30 minutes of strenuous physical activity every day to reduce the risk of cancer. For example, they suggest using a treadmill while watching TV or a step counter while conducting everyday life routines and keeping a training diary.

3

His diagnosis is thus far controlled with three different radiotherapies.

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Contributor Notes

Magdalena Skowronski is conducting a PhD study in social anthropology at the National Research Center in Complementary and Alternative Medicine (NAFKAM), The Arctic University of Norway (UiT). The study focuses on how chronic cancer patients sense and understand illness in everyday life, their care-seeking processes, and their therapeutic pathways in the healthcare system. E-mail: msk046@uit.no

Mette Bech Risør is mainly interested in researching symptoms and sensations in clinical encounters, as well as illness experiences and health-seeking practices, especially concerning functional disorders, cancer and lifestyle diseases. Her position at the General Practice Research Unit of UiT creates the basis for the interdisciplinary approach to both her research and teaching. E-mail: mette.bech@uit.no

Nina Foss is mainly interested in social and cultural processes between people who experience illness, their everyday relations and relations to health personnel, including alternative therapists. She has a special interest in how people with chronic illness cope in everyday life. E-mail: nina.foss@uit.no

Anthropology in Action

Journal for Applied Anthropology in Policy and Practice

  • BaklienB.B. Ytterhus and R. Bongaardt (2015) ‘When Everyday Life Becomes a Storm on the Horizon: Families’ Experiences of Good Mental Health while Hiking in NatureAnthropology & Medicine 23 no. 1: 4253. doi:10.1086/339561

    • Search Google Scholar
    • Export Citation
  • BenderB. (2002) ‘Time and LandscapeCurrent Anthropology 43 no. S4: 103112. doi:10.1086/339561

  • BjerkeT. (1993) Barn og natur - Teoretiske perspektiver og empiriske studier av barns og unges adferd i opplevelse av og holdninger til naturmiljøet [Theoretical perspectives and empirical studies of child and youth behaviour experience of and attitudes towards the natural environment] (Lillehammer: Lillprint AS).

    • Search Google Scholar
    • Export Citation
  • EmersonR.R. Fretz and L. Shaw (2011) Writing Ethnographic Fieldnotes (Chicago: The University of Chicago Press).

  • FlickU. (2012) Qualitative Sozialforschung – Eine Einfuehrung (Hamburg: Rowohlt Taschenbuch Verlag).

  • FolkvordS. and N. Foss (2013) Kombinering av konvensjonell og alternativ behandling ved lettere muskel- og skjelettlidelser (Tromsø, Norway: UiT The Arctic University of Norway) http://munin.uit.no/handle/10037/5788 (accessed 20 April 2016).

    • Search Google Scholar
    • Export Citation
  • FrykmanJ. and O. Löfgren (1987) Culture Builders: A Historical Anthropology of Middle-class Life (New Brunswick, NJ: Rutgers University Press).

    • Search Google Scholar
    • Export Citation
  • GeslerW. (1992) ‘Therapeutic Landscapes: Medical Issues in Light of the New Cultural GeographySocial Science & Medicine 34 no. 7: 735746. doi:10.1016/0277-9536(92)90360-3

    • Search Google Scholar
    • Export Citation
  • GullestadM. (1992) The Art of Social Relations: Essays on Culture Social Action and Everyday Life in Modern Norway (Oslo: Scandinavian University Press).

    • Search Google Scholar
    • Export Citation
  • GunnarB. (2003) ‘Nordmenn, høflighet og kunsten å omgås fremmede[Norwegians politeness and the art of avoiding strangers] Norsk antropologisk tidsskrift 14 no. 01: 1626.

    • Search Google Scholar
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