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

1. Old & New Medical Geography: A Shift to Health Geography? Professor Mark W. Rosenberg Queen’s University Department of Geography Department of Community Health and Epidemiology Kingston, Ontario, Canada, K7L 3N6 mark.rosenberg@queensu.ca

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

3. 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

4. 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

5. Cholera Deaths and the Broad Street Pump Map

6. 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 1600’s. • 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

7. Example of Disease Mapping at the Global Scale

10. 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

11. 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.

12. 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., women’s 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

13. 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., 1994:345) • 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

14. 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

15. 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

16. 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

17. (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).”

18. 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)

19. (2) Therapeutic Landscapes • Therapeutic landscapes are “places that have achieved lasting reputations for physical, mental, and spiritual healing” (Kearns and Gesler, 1998:8) • 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)

20. (3) Social Capital Theory • Social capital consists of the “actual or potential resources that inhere within social networks or groups for personal benefit” (Carpiano, 2006:166) • All social connections are not equal – resources available through one person’s 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

21. 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

22. (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 woman’s subordinate position in society is seen to be a function of social processes rather than ‘inferior’ biology.

23. (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, 1997:205) • Academia criticized for not providing an enabling environment for persons with disabilities. • e.g., Parallel Transit Service

24. (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

25. (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

26. 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

27. 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)

28. 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

29. 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