- Email: [email protected]
Place, space and health
Sot. Sci. Med.
Pergamon
0277-9536(94)00187-l
Vol. 39, No. 12, pp. 1589-1590, 1994 Copyright 0 1994 Elsevier Science Ltd Printed in Great Britain. All rights reserved 0277-9536/94 $7.00 + 0.00
EDITORIAL PLACE,
SPACE AND HEALTH HENRI
E. PICHERAL
It may never happen again and self-satisfaction is not a crime-Social Science & Medicine has been a pioneering journal for 37 years! It has had the great merit of bringing about the meeting and then the marriage of life science and social science. It very soon demonstrated and pleaded for the virtues of the interdisciplinary approach and became a recognised tribune now often copied in the scientific community. However, looking back on it, cannot one wonder about the very title of the journal and its scope and wonder whether the marriage has really been consummated? Doctors and epidemiologists have no doubt found answers or approaches to answers to their questions, and today they use the language of sociologists, anthropologists, economists, psychologists or geographers. The latter cannot remain indifferent to renewed interest on the part of epidemiologists and biostatisticians in place, in space and even in enuironment. The long hiatus following the success of fundamental and clinical medicine had almost reduced these concepts to the rank of old-fashioned, anachronistic accessories of medicine of the tellurist and hygienist schools. Their current re-emergence could have made them mediatory concepts in the centre of interdisciplinary debates. However, is it a good thing to mix genres and reverse roles and skills? It is true that any public health policy is aimed at identifying health priorities and populations at risk. Geographers contribute by locating them in space, but they are neither the first nor the only category to pursue this objective. Descriptive epidemiology and ‘geographical pathology’ preceded geography in this area before giving rise to what some refer to as ‘spatial’ epidemiology, that is to say the projection in space of biomedical data on morbibity and mortality. This consists in practice of plotting location and distribution maps showing more or less unequal frequencies and varying gradients of a disease. The final stage of analytical epidemiology leads to correlating these results with the geographical distribution of one or more variables considered to be risk factors within the same space. Use of increasingly refined statistical methods enables the validation of the significance of the relations observed and to support etiological hypotheses. The most complete conclusion of this procedure
is the elaboration of ‘geographical information systems’ (GIS) that automatically produce a series of maps. But it should be reminded that cartography is not geography. Anybody with the right equipment can produce maps today, but this does not make him a geographer. A certain distortion, or rather a narrow definition and view of ‘l’environnement’ (in French), have led most epidemiologists and a fair number of geographers for reasons of fashion or imitation to discard a term in their specific vocabularly-‘le milieu’. The latter term is not limited to the physical and biological conditions of a location but also includes its social, economic and cultural features, etc. Above all, ‘le milieu’ is not intangible and fixed and even less a simple neutral and undifferentiated variable. ‘Le milieu’ as a whole changes and evolves. This is doubtless the point of crossing and above all the point of divergence of the paths of epidemiology and geography. Epidemiologists and biostatisticians simply consider space as a variable among others and as a grid for examining and analysing their data. Space is thus in a way disincarnate and emptied of what forms its specificity. They care little about the scale they work on; they use spatial division based on an administrative ‘framework’ (region, province, administrative department, canton, etc.) for the sake of convenience. They discover in passing that a casual relation or a significant probability at one scale is not verified on another. It were as if space were a mere support, a plane homogenous surface, in short a kind of theatrical set! The geographer knows that space is a moving and changing reality and that its characteristics are the result of permanent development by a population or a society. Rural exodus, the abandoning of land or in contrast the conquest of new zones for agricultural or industrial purposes, migration, the massive urbanization spread and the modes of industrialization are processes with weighty consequences. They cause chain reactions that affect the populations themselves. Their demographic, social and economic characteristics evolve and their system of values changes. They age, grow younger, change jobs, incomes, life-style 1589
1590
Editorial
and place, behaviour etc., without counting the effects of political changes and the choices, role and place of the state. Analysis of place can therefore be only diachronic or synchronic. How can one distinguish between and separate time and space?
111 It would
of course be absurd to negate or forget the role of the ‘natural’ conditions of place. Elevation, latitude and the biophysical and biochemical qualities of the air, water and soil are not futile or inoperative concepts! However, the procedure will fall short if it results in as many geographies of disease as there are relations of cause and effect. Such a juxtaposition of ‘disciplinary’ sectorial analyses leads from narrow determinism contradicted by all proclamations concerning the plurifactorial and systemic nature of etiology of disease. Think only of the current mode of the spreads of AIDS and the resulting debate! However, such an approach above all ignores the properties of the environment and the societies in which the disease proceeds. The level of health of a population clearly reflects its capacity for adaptation to natural conditions and constraints and then to mastery of them thanks to management techniques and hence management and development of space. P. Gourou’s judgement is also valid outside the tropics [2]. Although the organization and management of space effectively obey a number of models, they are never identical. A population manages a space-its own space-where it lives, works, moves and generates fluxes (of men, goods and services, including medical services). It organizes it, uses it and identifies with it. It is here that geography of health differs from the geography of diseases and from medical geography, and affirms that it belongs to social geography [3,4]. A geographer seeks to know how health data reveal modes of organization and the spatial practices of populations in various places. The systemic hinging of this set of indicators of all kinds (biological, biogeographical, demographic, social, economic, cultural, political, etc.) leads to differentiation of space and hence inequalities. In other words, do levels of health (or absence of health) reflect a given level of development? Geographers seek to respond to the desires for equity in any health system in both its social and spatial dimensions. It is difficult to see how in this perspective the geographer would not incorporate the features and procedures of the health care system in his analysis. The volume and quality of health resources and above all their location in space (concentration vs diffusion) determine to a considerable extent their effective use and thus the degree to which the population calls on them. The health care system clearly depends on the choice of type of organization of
space; it is both the subject and object of regional developement. Who could legitimately affirm that the state of health of a population is unrelated to the resources available and the use it makes of them? [5] The organization of health services, in space and their use must henceforth be counted among the factors of risk of social inequality in health. And could one not measure individual and collective choices and the behaviour-rational or not-of a given population? These are all dictated by a system of references and values peculiar to a certain country, region, town or even urban district. One cannot minimize or neglect in this respect the behaviour of health personnel and institutions (public and private), their professional strategies and their own use of space. Such a procedure goes well beyond the ususal scope of medicine and epidemiology (in the usual sense) and even further beyond that of biostatistics. Without wishing to be provocative, the question raised here could be summarized as the choice between two titles: Social Science & Medicine or Social Science & Health. The words are not innocuous and cover different concepts and objectives. That health today is not limited to the mere absence of disease is now a truism. Likewise, people believe that better health is the mark of development, progress, social justice and well-being, and that, conversely, economic and social development contribute to better health [S]. Once these principles and postulates are accepted, it is impossible to measure health solely on the basis of biomedical standards. This is in no way a criticism and even less denigration of epidemiology and epidemiologists. Geographers are in their debt for having borrowed concepts, methods and rigour. Their approach is their own. However, it is surprising that some geographers feel obliged to take it over lock stock and barrel in a quest for scientific rigour or for ‘recognition’ by the scientific community. They give way to a kind of medicocentrism whereas geographers’ preoccupations are-or should be--elsewhere in questions of health and public health in particular. A clearly understood interdisciplinary feature should not lead to a confusion between genres, a single facade and illusory syncretism. REFERENCES
I. Carlstein T., Parkes D. N. and Thrift N. J. Timing Space and Spacing Time. Edwards Arnold, London, 1978. 2. Gourou P. Terres de bonne espPrance. Le monde tropical.
Plon, Paris, 1982. Woods K. J. The Social Geography of Health. Croom Helm, London. 1983. Moon G. Health, Disease and Society: an to Medical Geography. Routledge & Kegan, London, 1987. 5. Jamieson D. T. et al. World Development Report 1993. Oxford University Press, Oxford, 1993.
3. Eyles J. and Medicine and 4. Jones K. and Introduction
Pergamon
0277-9536(94)00187-l
Vol. 39, No. 12, pp. 1589-1590, 1994 Copyright 0 1994 Elsevier Science Ltd Printed in Great Britain. All rights reserved 0277-9536/94 $7.00 + 0.00
EDITORIAL PLACE,
SPACE AND HEALTH HENRI
E. PICHERAL
It may never happen again and self-satisfaction is not a crime-Social Science & Medicine has been a pioneering journal for 37 years! It has had the great merit of bringing about the meeting and then the marriage of life science and social science. It very soon demonstrated and pleaded for the virtues of the interdisciplinary approach and became a recognised tribune now often copied in the scientific community. However, looking back on it, cannot one wonder about the very title of the journal and its scope and wonder whether the marriage has really been consummated? Doctors and epidemiologists have no doubt found answers or approaches to answers to their questions, and today they use the language of sociologists, anthropologists, economists, psychologists or geographers. The latter cannot remain indifferent to renewed interest on the part of epidemiologists and biostatisticians in place, in space and even in enuironment. The long hiatus following the success of fundamental and clinical medicine had almost reduced these concepts to the rank of old-fashioned, anachronistic accessories of medicine of the tellurist and hygienist schools. Their current re-emergence could have made them mediatory concepts in the centre of interdisciplinary debates. However, is it a good thing to mix genres and reverse roles and skills? It is true that any public health policy is aimed at identifying health priorities and populations at risk. Geographers contribute by locating them in space, but they are neither the first nor the only category to pursue this objective. Descriptive epidemiology and ‘geographical pathology’ preceded geography in this area before giving rise to what some refer to as ‘spatial’ epidemiology, that is to say the projection in space of biomedical data on morbibity and mortality. This consists in practice of plotting location and distribution maps showing more or less unequal frequencies and varying gradients of a disease. The final stage of analytical epidemiology leads to correlating these results with the geographical distribution of one or more variables considered to be risk factors within the same space. Use of increasingly refined statistical methods enables the validation of the significance of the relations observed and to support etiological hypotheses. The most complete conclusion of this procedure
is the elaboration of ‘geographical information systems’ (GIS) that automatically produce a series of maps. But it should be reminded that cartography is not geography. Anybody with the right equipment can produce maps today, but this does not make him a geographer. A certain distortion, or rather a narrow definition and view of ‘l’environnement’ (in French), have led most epidemiologists and a fair number of geographers for reasons of fashion or imitation to discard a term in their specific vocabularly-‘le milieu’. The latter term is not limited to the physical and biological conditions of a location but also includes its social, economic and cultural features, etc. Above all, ‘le milieu’ is not intangible and fixed and even less a simple neutral and undifferentiated variable. ‘Le milieu’ as a whole changes and evolves. This is doubtless the point of crossing and above all the point of divergence of the paths of epidemiology and geography. Epidemiologists and biostatisticians simply consider space as a variable among others and as a grid for examining and analysing their data. Space is thus in a way disincarnate and emptied of what forms its specificity. They care little about the scale they work on; they use spatial division based on an administrative ‘framework’ (region, province, administrative department, canton, etc.) for the sake of convenience. They discover in passing that a casual relation or a significant probability at one scale is not verified on another. It were as if space were a mere support, a plane homogenous surface, in short a kind of theatrical set! The geographer knows that space is a moving and changing reality and that its characteristics are the result of permanent development by a population or a society. Rural exodus, the abandoning of land or in contrast the conquest of new zones for agricultural or industrial purposes, migration, the massive urbanization spread and the modes of industrialization are processes with weighty consequences. They cause chain reactions that affect the populations themselves. Their demographic, social and economic characteristics evolve and their system of values changes. They age, grow younger, change jobs, incomes, life-style 1589
1590
Editorial
and place, behaviour etc., without counting the effects of political changes and the choices, role and place of the state. Analysis of place can therefore be only diachronic or synchronic. How can one distinguish between and separate time and space?
111 It would
of course be absurd to negate or forget the role of the ‘natural’ conditions of place. Elevation, latitude and the biophysical and biochemical qualities of the air, water and soil are not futile or inoperative concepts! However, the procedure will fall short if it results in as many geographies of disease as there are relations of cause and effect. Such a juxtaposition of ‘disciplinary’ sectorial analyses leads from narrow determinism contradicted by all proclamations concerning the plurifactorial and systemic nature of etiology of disease. Think only of the current mode of the spreads of AIDS and the resulting debate! However, such an approach above all ignores the properties of the environment and the societies in which the disease proceeds. The level of health of a population clearly reflects its capacity for adaptation to natural conditions and constraints and then to mastery of them thanks to management techniques and hence management and development of space. P. Gourou’s judgement is also valid outside the tropics [2]. Although the organization and management of space effectively obey a number of models, they are never identical. A population manages a space-its own space-where it lives, works, moves and generates fluxes (of men, goods and services, including medical services). It organizes it, uses it and identifies with it. It is here that geography of health differs from the geography of diseases and from medical geography, and affirms that it belongs to social geography [3,4]. A geographer seeks to know how health data reveal modes of organization and the spatial practices of populations in various places. The systemic hinging of this set of indicators of all kinds (biological, biogeographical, demographic, social, economic, cultural, political, etc.) leads to differentiation of space and hence inequalities. In other words, do levels of health (or absence of health) reflect a given level of development? Geographers seek to respond to the desires for equity in any health system in both its social and spatial dimensions. It is difficult to see how in this perspective the geographer would not incorporate the features and procedures of the health care system in his analysis. The volume and quality of health resources and above all their location in space (concentration vs diffusion) determine to a considerable extent their effective use and thus the degree to which the population calls on them. The health care system clearly depends on the choice of type of organization of
space; it is both the subject and object of regional developement. Who could legitimately affirm that the state of health of a population is unrelated to the resources available and the use it makes of them? [5] The organization of health services, in space and their use must henceforth be counted among the factors of risk of social inequality in health. And could one not measure individual and collective choices and the behaviour-rational or not-of a given population? These are all dictated by a system of references and values peculiar to a certain country, region, town or even urban district. One cannot minimize or neglect in this respect the behaviour of health personnel and institutions (public and private), their professional strategies and their own use of space. Such a procedure goes well beyond the ususal scope of medicine and epidemiology (in the usual sense) and even further beyond that of biostatistics. Without wishing to be provocative, the question raised here could be summarized as the choice between two titles: Social Science & Medicine or Social Science & Health. The words are not innocuous and cover different concepts and objectives. That health today is not limited to the mere absence of disease is now a truism. Likewise, people believe that better health is the mark of development, progress, social justice and well-being, and that, conversely, economic and social development contribute to better health [S]. Once these principles and postulates are accepted, it is impossible to measure health solely on the basis of biomedical standards. This is in no way a criticism and even less denigration of epidemiology and epidemiologists. Geographers are in their debt for having borrowed concepts, methods and rigour. Their approach is their own. However, it is surprising that some geographers feel obliged to take it over lock stock and barrel in a quest for scientific rigour or for ‘recognition’ by the scientific community. They give way to a kind of medicocentrism whereas geographers’ preoccupations are-or should be--elsewhere in questions of health and public health in particular. A clearly understood interdisciplinary feature should not lead to a confusion between genres, a single facade and illusory syncretism. REFERENCES
I. Carlstein T., Parkes D. N. and Thrift N. J. Timing Space and Spacing Time. Edwards Arnold, London, 1978. 2. Gourou P. Terres de bonne espPrance. Le monde tropical.
Plon, Paris, 1982. Woods K. J. The Social Geography of Health. Croom Helm, London. 1983. Moon G. Health, Disease and Society: an to Medical Geography. Routledge & Kegan, London, 1987. 5. Jamieson D. T. et al. World Development Report 1993. Oxford University Press, Oxford, 1993.
3. Eyles J. and Medicine and 4. Jones K. and Introduction