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medical geography

  Geographical analyses of health, disease, mortality and health care. The relationships between environment and patterns of ill-health or mortality have long exercised the attention of geographers and the antecedents of this tradition continue to be explored, demonstrating the antiquity of medical geography. The ecology of disease has attracted most attention, providing opportunities for demonstrations of a range of quantitative methodologies for spatial analysis. In their most basic form such analyses have a strongly cartographic orientation, permitting comparisons of the pattern of disease with the distribution of presumed environmental risks. One of the most famous illustrations is Dr John Snow\'s map of cholera cases in central London in 1849, which demonstrated a concentration of cholera deaths in households which drew water from a particular pump. Snow suspected that contamination in the water supply might have a relationship to the cholera deaths and shutting off the pump accelerated the decline in the number of new cases of the disease — though, as has often been observed, the decline had begun before the pump was shut off. Quantitative analyses have illustrated the relationships between patterns of material prosperity or deprivation and patterns of mortality, sometimes showing, with the aid of reconstruction of mortality series over time, that areas of high mortality have persisted for many years (Dorling, 1997), and also demonstrating the strength of the gradient in mortality experience between prosperous and poor localities. The complication here is determining precisely what role place has in explaining these patterns: are mortality variations simply a resultant of other patterns of socio-economic disadvantage, or are there independent, contextual effects of place? Put another way, how do we — for simplicity — disentangle the relationships between area, class and health (McIntyre et al., 1993)? There is growing acceptance among social scientists that place does make a difference and that it needs to be theorized, conjointly and concurrently with other planes of social division (Popay et al., 1998).

In some circumstances medical geography\'s traditional emphasis on associations between environment and disease has made valuable contributions, notably in less-developed societies where the connections between environmental influences and disease are relatively transparent (Phillips and Verhasselt, 1994). But there have been considerable achievements elsewhere. Sophisticated methods have been developed, often in parallel with developments in epidemiology, to assess the degree of association between patterns of diseases and associated environmental factors. Three forms of analysis may be mentioned. First, particularly with diseases which occur in small numbers, only point-pattern data are available and so attempts must be made to assess the degree of clustering in spatial distributions; Openshaw\'s Geographical Analysis Machine was an ambitious attempt to achieve this in the context of debates about \'cancer clusters\' in northern England (Openshaw, 1990; cf. geocomputation). Secondly, there have been exercises in modelling the diffusion of diseases such as measles and, more recently, AIDS (Cliff, Haggett and Smallman-Raynor, 1988; Shannon and Pyle, 1989; Gould, 1993). These have been of value in assisting the control of the further spread of such afflictions. Thirdly, recent studies have emphasized the complexity of the relationships between social status and health, seeking to use multilevel modelling techniques to evaluate how individual and area effects interact; such techniques have been used in predictions of health-related behaviour (Duncan et al., 1993).

The foregoing has emphasized geographies of mortality and physical illness. However, geographies of mental illness have also received attention. There are well-known empirical regularities in the distribution of the mentally ill, notably that there are high rates of illness in impoverished areas, but the causal connections are not clear. Are causes to be found in areal characteristics (the \'breeder\' hypothesis) or do individuals prone to mental illness gravitate to particular areas (the \'drift\' hypothesis)? The debate on this generated one of the best-known examples of the ecological fallacy: while an association could be demonstrated between high incidence of mental illness and social conditions, quite contradictory inferences could be drawn with respect to causal processes (Giggs, 1973).

Geographical analyses have also been applied to the study of patterns of healthcare delivery. Some authors maintain that there are consequently \'two traditions\' of medical geography, one focusing on health services, the other addressing mortality and morbidity; there have been persistent calls for the integration of the two (e.g. Mayer, 1982). However, it is not clear that this is a particularly productive debate; more heat than light has been expended on an issue which really amounts to little more than the statement that some medical geographers have rather different objects of study. Few geographers have attempted simultaneously to model geographies of health services with geographies of disease in order to assess the impact of the former on the latter. Instead, rather than assessing variations in the efficacy of services, concern has been focused on the degree of equity in spatial distributions of health services, and on the development and application of techniques for better spatial planning (Joseph and Phillips, 1984; Haynes, 1987). Implicit in this is a judgement that health facilities per se are unproblematically beneficial, a judgement which might not be shared by all and which has led to questioning of the biomedical model of health and health care. Following a concern with geographies of human welfare, many studies have analysed the extent of geographical variability in health-care provision and the extent of correspondence with social need. Even within ostensibly egalitarian services, important spatial variations have been identified, and evidence has been provided for Hart\'s famous \'inverse care law\', which suggests that services allocated under market criteria are inversely related to patterns of need (Powell, 1990). Particularly in health-care systems where they are no financial barriers to use of services, attention has also focused on patterns of utilization, with a view to determining which groups are able to make most use of services and demonstrating the extent to which use of services declines with — and is constrained by — distance from facilities (cf. distance decay). This has been a debate of fundamental importance in resource allocation decisions; some believe that high levels of hospital utilization are a function of the pattern of existing institutions, whereas others suggest that high levels of utilization reflect greater social need (Royston et al., 1990). There are also numerous examples of the application of geographical techniques in health-care planning, such as location-allocation modelling, which is used extensively by health-care providers to determine optimum arrangements of services, notably in less-developed societies where health-care systems are still being established (Phillips and Verhasselt, 1994).

These developments in medical geography have not been without their critics. First, the aggregate and ecological approach of many geographies of mortality and illness has been criticized for undertheorizing the social and political determinants of inequalities in health and for failing adequately to link aggregate and individual approaches (which may be partly overcome, using multilevel modelling). Secondly, there has been an overemphasis on the spatial and locational attributes of health-care systems, but this has been criticized for offering a limited understanding of how spatial patterns of services actually evolve, away from the isotropic plain of the spatial analyst, and for an overemphasis on spatial factors to the neglect of social constraints. Finally, in analysing patterns of health and health care, attention has to be given to other social cleavages — race, gender, disability, sexuality — as well as to spatial differentiation. For all these reasons, there are growing signs of what some term a \'post-medical geography\', in which the concern is with matters of individual and community identity, and with determining what elements of place shape individuals\' health experiences and access to services (see public services, geography of). Institutionally, the renaming of the medical geography study groups of the RGS/IBG and the AAG as the \'geography of health and health care\' research groups, is indicative of this shift in orientation (see health and health care, geography of).

The attractions and limitations of conventional approaches to medical geography are well illustrated by a consideration of geographical studies of AIDS. The application of spatial analysis took three forms: modelling the global diffusion of AIDS; tracking the progress of the virus within states; and, on the basis of these analyses, attempting to predict likely future geographies of AIDS (Shannon and Pyle, 1989; Gould, 1993). Such work made an important contribution to understanding likely spatial patterns of diffusion but had less to say about the causes of AIDS and about the experiences of those affected. Brown (1995), in an argument with broader applicability to medical geography, suggests that the focus of diffusion studies is on the virus, which allows a social distance to be maintained between researchers and those affected by, and coping with, AIDS (Kearns, 1996). Studies of the lives of people with AIDS (PWAs) demonstrate a move away from the geometric conception of space of diffusion studies, to an analysis of the importance of place, either in constructing the experience of PWAs, or in shaping community responses to the disease (Wilton, 1996). Constructing knowledge of health and health care thus depends on understanding the meaning and experience of place (Kearns and Joseph, 1993, p. 715). (JM)

References Brown, M. 1995: Ironies of distance: an ongoing critique of the geographies of AIDS. Environment and Planning D: Society and Space 13: 159-83. Cliff, A.D., Haggett, P. and Smallman-Raynor, M. 1988: An atlas of disease distributions. Cambridge: Cambridge University Press. Dorling, D. 1997: Death in Britain. York: Joseph Rowntree Foundation. Duncan, C., Jones, K. and Moon, G. 1993: Do places matter? A multilevel analysis of regional variations in health-related behaviour in Britain. Social Science and Medicine 37: 725-35. Giggs, J.A. 1973: The distribution of schizophrenics in Nottingham. Transactions, Institute of British Geographers 59: 55-76. Gould, P. 1993: The slow plague. Oxford: Blackwell. Haynes, R. 1987: The geography of health services in Britain. London: Croom Helm. Joseph, A. and Phillips, D. 1984: Accessibility and utilisation: geographic perspectives on health care delivery. London: Longman. Kearns, R. 1996: AIDS and medical geography: embracing the other? Progress in Human Geography 20: 123-31. Kearns, R. and Joseph, A. 1993: Space in its place: developing the link in medical geography. Social Science and Medicine 37: 711-17. McIntyre, A. et al. 1993: Area class and health: should we be focusing on places or people? Journal of Social Policy 22: 213-34. Mayer, J. 1982: Relations between two traditions of medical geography. Progress in Human Geography 6: 216-30. Openshaw, S. 1990: Automating the search for cancer clusters: a review of problems, progress and opportunities. In R.W. Thomas, ed., Spatial epidemiology. London: Pion, 48-78. Phillips, D. and Verhasselt, Y., eds, 1994: Health and development. London: Routledge. Popay, J. et al. 1998: Theorising inequalities in health: the place of lay knowledge. Sociology of Health and Illness 20: 619-44. Powell, M. 1990: Need and provision in the NHS, an inverse care law. Policy and Politics 18: 31-7. Royston, G. et al. 1990: Modelling the use of health services by populations of small areas to inform the allocation of central resources to larger regions. Socio-Economic Planning Sciences 26: 169-90. Shannon, G. and Pyle, G. 1989: The origin and diffusion of AIDS: a view from medical geography. Annals of the Association of American Geographers 79: 1-24. Shannon, G. et al. 1991: The geography of AIDS. New York: Guilford. Wilton, R. 1996: Diminished worlds? The geography of everyday life with HIV/ AIDS. Health and Place 2: 69-84.



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