Introduction

1. Introduction • The main concerns of Geography may be summarized by the words ‘place’, ‘space’ and ‘environment’. • Environment: How people influence and are influenced by their environment, both physical and human (i.e. cultural, poltical, social, economic).

2. Introduction … • Space: How things vary over space, and how spatial variations in one thing influence spatial variations in other things. • Place: How the combination of factors found at a place make that place unique. People’s subjective attachment to places.

3. Definitions 1. Medical geography is the application of geographical perspectives and methods to the study of health, disease and health care. • Johnston et al., (1994) Dictionary of Human Geography, p.374.

4. Definitions… 2. Medical geography uses the concepts and techniques of the discipline of geography to investigate health-related topics. • Subjects are viewed in holistic terms within a variety of cultural systems and a diverse biosphere. • Draws freely from the facts, concepts and techniques of other social, physical, and biological sciences. • Medical geography is an integrative, multi­stranded subdiscipline that has room within its broad scope for a wide range of specialist contributions. • Meade and Earickson (2000) Medical Geography, p.1

5. Medical Geography … • Geographic variation in health has long been studied in interdisciplinary rubrics as: • Geographic pathology • Medical ecology • Medical topography • Geographical epidemiology • Geomedicine • Medical climatology etc.

6. Sub-Branches • A distinction is sometimes made between Medical Geography and Health Geography. • Health geographers tend to focus on place as opposed to space or environment. They also tend to focus on subjective aspects (e.g. illness, as opposed to disease) and tend to favour the use of both qualitative and quantitative methodologies. • The main division in Medical / Health Geography is between the geography of health (i.e. the causes of diseases) and the geography of health care (i.e. the provision and uptake of medical services).

7. Medical Geography Criticized • The new generation of health geographers, in reaction to the previous medical geographer's view of the discipline, state: • Our reply is that this dominant 'biomedical' viewpoint is both flawed and limited. • There is an urgent need to 'go outside the body' to develop an alternative social and environmental perspective on health in which geography can play an important part, along with other social sciences (Jones and Moon, 1989).

8. Medical Geography Criticized… • Local variations in health status and health care provision are certainly important, but the principal concerns of medical geography as currently practised -access to and the location of and utilization of health facilities, the use of quantitative techniques for spatial analysis in health care planning or the socio-political determinants of health and access to health care­-are limiting. • Medical geography requires radical surgery if it is truly to come to grips with such issues (Mohan, 1989).

9. Medical Geography Criticized… • In the marriage of humanistic geography and contemporary models of health suggested by these writers, we have an incipient "post-medical" geography of health (Kearns, 1993). • Therefore there are two strands of medical geography: the traditional and contemporary

10. Medical Geography Criticized… • The 'traditional' strands accept disease as a naturally occurring, culture-free, and 'real' entity, where the problems posed by questions of accurate measurement and distribution are assumed to be technical and solvable.

11. Medical Geography Criticized … • In contrast, the other 'contemporary' strands adopt a stance which argues, in various ways, that notions of health, disease, and illness are problematic, and intimately linked to power relations in society. • Thus, the assumption of health professionals as invariably caring, neutral scientists is questioned, and the different roles they fulfill in maintaining the current social order become subjects for scrutiny (Curtis and Taket, 1996).

12. Medical Geography Criticized … • “Medical geography" … too narrow -- "health geography" preferred now, much more in tune with debates in social theory and policy • Special role for “place" - physical space, place in the world, and sense ofplace.

13. Some Questions? • What is Health? • What is Disease? • What is illness?

14. Health • Everyone knows what health is, and yet a precise definition of health is difficult to come by • Health: ‘is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ (WHO, 1947) • However, in practice ‘health’ tends to be regarded as the absence of disease.

15. Disease • May (1961) defined disease as “that alteration of living cells or tissues, that jeopardizes survival in their environment” • Disease refers to an objective ‘malfunction’ (i.e. adverse physical condition), irrespective of whether the person feels unwell (e.g. hypertension – high blood pressure).

16. Disease … • Is that which is diagnosed by a physician • It is usually believed to be located in specific organs or systems in the body and curable through specific biomedical treatments. • Disease is a socially mediated event

17. Disease … • Several important points in the definition of disease: • The organism has an environment • The idea that disease jeopardizes survival implies there may be different levels of health without there being disease • E.g., an office worker does not need the physique or eyesight of a hunter

18. Metaphoric Meanings of Disease • Metaphors attached to diseases are often destructive and harmful. • They frequently lead to punitive effects on the patient because they exaggerate, simplify, and stereotype the patient's experience. • Metaphors may function as stigma. • They may serve to isolate the person with the disease from the community.

19. Metaphoric Meanings of Disease … • Metaphors often imply adverse moral and psychological judgements about the ill person. • They have perpetrated the view, for example, that cancer is a form of self‑judgement or self‑betrayal.

20. Media Images of Cancer, Heart Disease, and AIDS • A study of the way cancer, heart disease, and AIDS have been portrayed in the mass media illustrates how diseases come to have unique meanings and metaphors associated with them. • Disease is seen as much more than a mechanical failure and a physiological pathology • Table 1

21. Images of Cancer, Heart Disease and AIDS Table 1 - Source: Clarke, 2004

22. Media Images of Cancer • The moral worth of the person with cancer is attacked by the invasion of an evil predator so fearsome it is not even to be named, but fought as a powerful alien intruder that spreads secretly through the body. • The person with cancer is not offered much hope of recovery.

23. Media Images of Cancer… • By and large, the media portray cancer as associated with horrid symptoms, mutilations, excruciating suffering, and finally death. • To some extent the person with cancer is held to be blameworthy because the cancer could have been detected through medical checkups etc.

24. Media Images of Cancer… • There is a great deal of uncertainty about the cause of cancer. • There are numerous putative causes. • They are usually described as the result of individual lifestyle decisions. • The individual who is ultimately culpable.

25. Media Images of Heart Disease • The media description is radically different when the disease is a heart attack. • The heart attack is presented as an objective, morally neutral event that happens at a specific time and place and causes a great deal of pain. • Heart disease is portrayed in optimistic terms.

26. Media Images of Heart Disease … • Not only are there very clear and precise steps to be taken to prevent it, but when it occurs it can be treated in a variety of mechanical ways, including using technology to replace a malfunctioning heart. • Heart disease does not affect the whole person or the moral being of the person. • It 'attacks' one part only.

27. Media Images of Heart Disease … • Heart disease is an outsider that can be repelled through quick, 'decisive’ action and the use of medical marvels. • The person with heart disease may experience acute fear and pain, but the period of recovery is likely to be dominated by optimism about a cure and a resolve to change the lifestyle habits that led to the disease in the first place.

28. Media Images of AIDS • The person with AIDS is portrayed as a diseased person and as somewhat morally repugnant. • S/he is described as hopelessly doomed and isolated from potentially significant sources of emotional support such as lovers and family members. • The disease itself is described in mechanical and biomedical terms.

29. Media Images of AIDS … • The media do not dwell on the painful or debilitating symptoms of the disease. • They do not focus on the inevitable terminal stages of the disease, on death itself, or on the mortality rate.

30. Media Images of AIDS … • Rather, they focus on the fear of contagion and the uncertainty about the causes of contagion. • The person afflicted with AIDS is stigmatized because of the connection with a deviant lifestyle • Isolation

31. Illness • Illness: subjective feeling of feeling unwell (‘disease’), even if there are no apparent symptoms. • The experience of being ill draws from the symbolic interactionist tradition: • it draws attention to: • the meanings • interpretations • world views of human beings in relation to illness, sickness, disease, and death.

32. Illness … • Meanings are constructed out of social interactions in specific social, political, economic, and historical contexts. • Meanings reflect a person's position in the social structure and that person’s personal relationships and experiences.

33. Culture and Illness • Cultural attitudes to illness vary • The meaning of illness to people also vary • Physicians have been mostly concerned with the biomedical aspects of this complex • But patients have developed their own lay theories of illness causation ‑ and have given certain illnesses a metaphoric meaning which creates a totally different universe in which doctors usually feel completely lost.

34. Illness … • Variations in the experience of being ill • In all societies people experience illness, pain, disability, and disfigurement. • Possible causes of disease. • sorcery, • the breaking of a taboo • the intrusion of a disease causing spirit into the body • the intrusion of a disease‑causing object into the body • the loss of the soul

35. Illness … • All the above explanations, except for the intrusion into the body of a disease‑causing object, involve the supernatural or magic in an attempt to understand illness.

36. Illness … Westners • Westerners tend to see illness as empirically caused and mechanically or chemically treatable. • To a large extent, Westerners have separated the mind, the body, and the spirit.

37. Illness … Non-Westerners • However, in most of the non‑western world, non‑empirical explanations and cures for disease seem to dominate: • illness is seen as a combination of • spiritual • mental • physical phenomena.

38. Sickness • Refers to the social actions taken by person as a result of illness or disease, such taking medication, visiting the doctor, resting in bed, or staying away from work. • Patients feel illness and sickness • Sickness is a socially mediated event • Social-cultural factors influence whether a person visits a doctor, chiropractor etc.

39. Sickness … • Refers to the social actions taken by person as a result of illness or disease, such taking medication, visiting the doctor, resting in bed, or staying away from work. • Patients feel illness and sickness • Sickness is a socially mediated event • Social-cultural factors influence whether a person visits a doctor, chiropractor etc.