Old & New Medical Geography: A Shift to Health Geography?

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Old New Medical Geography A Shift to Health
Geography?
Professor Mark W. Rosenberg Queens
University Department of Geography Department of
Community Health and Epidemiology Kingston,
Ontario, Canada, K7L 3N6 mark.rosenberg_at_queensu.ca

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Introduction

• What is Medical Geography?
• Medical Geography Approaches
• A Shift to Health Geography?
• New Ways of Looking at Old and New Problems
• Concluding Comments

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What is Medical Geography?

• The term was first applied in the 1700s to
  describe studies of the relationship between
  disease and the environment
• Medical geography applies human geography methods
  and approaches to understand spatial influences
  on human health, such as
• How regional differences explain geographical
  variations in disease
• How changes to the physical environment affect
  rates of disease
• Understanding patterns of disease as a tool for
  prevention

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History of Disease

• Medical geography has been strongly influenced by
  parallel developments in epidemiology and public
  health
• The origins of medical geography are, therefore,
  tied to developments in these areas
• Early beliefs
• Ancient Greece - Hippocrates first to pursue
  rational bases for the presence of disease
• Ancient China Yin and Yang
• 1800s John Snow identified the source of
  cholera often seen as the first medical geographer

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Cholera Deaths and the Broad Street Pump Map
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Disease Mapping

• Distinct for its interest in the incidence and
  prevalence of disease .
• The mapping of morbidity and mortality at various
  geographic scales
• Examples of disease mapping trace back to the
  spread of the plague in the 1600s.
• A useful tool for exploring how diseases spread
  and identifying the locational origin of a
  disease.
• Unless we have a good understanding of the cause
  of a disease the approach may be of limited use.
• Tends to rely on large samples

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Example of Disease Mapping at the Global Scale
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Disease Ecology

• Disease ecology aims to understand the spatial
  and temporal patterns of disease
• Rather than reducing disease into isolated
  influences the approach considers the system as a
  whole
• Focus on the relationship between disease and the
  environment climate, plant and animal life etc.
• Differs from epidemiology which seeks to
  understand the causes of disease
• Cause rarely identified in medical geography
  usually we only get an indication of the strength
  of a relationship
• Environment can also include the social and
  psychological environment meaning that place
  matters increasingly.
• e.g., environmental inequality and circulatory
  disease

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Access, Delivery, and Health Service Planning

• The Geography of Medical Resources
• Three key issues
• Whether the geographical distribution of
  resources is equitable
• How accessible are medical resources to various
  segments of a population
• What are the social and economic impacts of
  locating medical resources at a particular
  location.

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Access, Delivery, and Health Service Planning

• The Geography of Medical Resources
• Location and distance are key variables
• An equal distribution of medical resources does
  not necessarily mean people have access to those
  medical resources
• Distinguishing between geographical, economic and
  social-cultural access
• e.g., womens access to cervical screening
  services
• The focus on social and economic impacts of
  siting facilities in particular locations
  stimulated by the deinstitutionalization of
  mental health services in the 1970s

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Location-Allocation Modeling

• Location-Allocation modeling dates back to the
  1960s
• Used in many aspects of geography, particularly
  retail studies to determine the optimal location
  of current facilities (hospitals, offices,
  warehouses, etc.) in order to minimize movement
  and other costs (Johnston et al., 1994345)
• Key concepts demand, supply and capacity
• This form of modeling was initially statistical
  now relies more on GIS
• Medical geographers interested in the physical
  accessibility of medical clinics, hospitals,
  speed with which ambulances may reach patients
  etc.
• e.g., optimization of location of emergency
  services

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Access, Delivery, and Health Service Planning

• Three trends in current research based on the
  geography of medical resources
• Research much more closely tied to specific
  policy issues faced by governments
• Research targeted towards particular groups who
  might be disadvantaged in accessing services
  specifically related to their health needs
• Incorporation of qualitative research into
  studies of geographic access and the social and
  economic impacts of siting facilities

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The Shift to Health Geography

• The shift is characterized by the emergence of
  new themes and new ways of investigating these
  themes a methodological pluralism?
• Greater interest in the socio-spatial and
  economic determinants of health has led to the
  stronger presence of theory than in medical
  geography.
• Greater focus on the importance of place while
  space continues as an important theme.
• Location is usually a fixed point in space
• Space is more relative and often connected to
  time
• Places are locations imbued with meaning

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The Shift to Health Geography

• Changing definitions of health
• Alma Ata Declaration defined health as
• a state of complete physical, mental and
  social wellbeing, and not merely the absence of
  disease or infirmity
• Health seen as a fundamental human right
• Underlined the importance of social, economic,
  and political equity in health
• Growing influence of the population health
  perspective

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(1) Population Health Approach

• population health refers to the health of a
  population as measured by health status
  indicators and as influenced by social, economic,
  and physical environments, personal health
  practices, individual capacity and coping skills,
  human biology, early childhood development, and
  health services. As an approach, population
  health focuses on interrelated conditions and
  factors that influence the health of populations
  over the life course, identifies systematic
  variations in their patterns of occurrence, and
  applies the resulting knowledge to develop and
  implement policies and actions to improve the
  health and well being of those populations (Dunn
  and Hayes).

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The Social Determinants of Health

• income inequality
• social inclusion and exclusion
• employment and job security
• working conditions
• contribution of the social economy
• early childhood care
• education
• food security
• housing
• (Public Health Agency of Canada)

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(2) Therapeutic Landscapes

• Therapeutic landscapes are places that have
  achieved lasting reputations for physical,
  mental, and spiritual healing (Kearns and
  Gesler, 19988)
• Intends to gain an understanding of historical
  sites as places of healing unique to the
  experiences of the individual
• The social/cultural reputations of these places
  are built on the physical environment (e.g., spa
  towns)
• Ethnographic (e.g., the representation of former
  asylums in contemporary landscapes) vs.
  experiential studies (e.g., the meaning of
  therapeutic places to seniors)

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(3) Social Capital Theory

• Social capital consists of the actual or
  potential resources that inhere within social
  networks or groups for personal benefit
  (Carpiano, 2006166)
• All social connections are not equal resources
  available through one persons family or friends
  may differ with socio-economic status
• Those with greater social capital also experience
  better health status
• At the group level social capital can lead to
  greater access to resources

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Social Capital Theory Health Geography

• Linking Health and Place
• place effects versus individual factors in
  understanding geographic variations in health
  status
• At the micro-level detailed studies of
  neighbourhood attributes comparing rich and poor
  neighbourhoods and people in good and poor health
• At the macro-level large scale statistical
  studies using multi-level modeling to estimate
  the contributions that individual factors and
  place effects make separately and in combination

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(4) Embodied Geographies

• Cartesian mind/body dualism 15th C
• Biological determinism
• e.g., human genome project
• Social constructionists have highlighted how
  dangerous biological determinism can be
• Social constructionists argue that the body is
  shaped by the social and cultural meanings
  ascribed to it.
• Hall (2000) explains that a womans subordinate
  position in society is seen to be a function of
  social processes rather than inferior biology.

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(5) Critical Disability Studies

• The approach frequently aims to include people
  living with disabilities in research and activism
• Dismisses the need for resources to be
  distributed equally (as advocated by the welfare
  state) to instead ensure individuals and groups
  are enabled to participate in the mainstreams of
  social life in meaningful ways (Gleeson,
  1997205)
• Academia criticized for not providing an enabling
  environment for persons with disabilities.
• e.g., Parallel Transit Service

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(6) Health and the Environment

• Linking Health and the Environment
• Impacts of high profile environmental disasters
• Psycho-social impacts of living near potential or
  real sources of environmental contamination
• How the environment in which we live affects
  particular health behaviours (e.g., smoking)
• Influenced by the new cultural geography,
  public health and health promotion research
• Climate change research and its impacts on health
  

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(7) Activist Epistemologies

• The emergence of activist epistemologies
• Critical Perspectives
• Distinct for their focus on producing social
  change through research
• Research is viewed as a means of giving voice to
  political and social movements
• Prevalence of Health Geography literature focused
  on health inequalities
• The role of participatory research approaches
• e.g., critical disability studies

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New Ways of Looking at Old New Problems

• Developments in the Geography of Disease Mapping
• New impetus because of new emerging diseases
  (e.g., HIV/AIDS and SARS)
• Improvements in data gathering
• Importance of improved electronic databases and
  population health surveys
• New techniques for analysing data
• GIS
• Spatial Statistics
• Multi-level modeling

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New Ways of Looking at Old New Problems

• New geographies being created through experiments
  with telehealth
• Public sector restructuring, the growth in
  importance of supra-national bodies (e.g., the
  World Bank) and globalization
• New social theories and qualitative methods
  (e.g., participant observation, interviews, focus
  groups, photovoice, participatory action research)

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Conclusions

• Medical/health geography is on a growth
  trajectory within geography and health research
• Remains rooted in classic geographic questions
  about identifying and explaining the geographic
  distribution of diseases and medical resources
• Recognition of the importance of the latest
  quantitative and qualitative methodological tools

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Conclusions

• Medical geography is recasting itself as health
  geography by taking up the challenges of linking
  health and the environment, health and place and
  health and health care to public policy
• Greater focus on vulnerable groups and their
  everyday lives in which health and health care
  play themselves out in developing and developed
  countries